V 


^^ 


51^ 


x^^ 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 


/  :> 


•3J  ^   ts  ^ 


#   0  &    -* 

I'   . 


t 


m  ~ 

t 


o 


•  ^^%  M. 


J I 


seifi 

gg'{S 

#      »T  1^  & 

It! 


^s> 


m  <w       •■r       wt 

O  5l  1:  ©  Hi 


"'JSd 


3  o 


..  •  a  ^ 


CV3 

G 

a 


f 


^  si  m 

I  It 


§ 


C/5 

o 


g   <s  ♦»        l< 

t^  .^  u»  ;3  ^ 

"^   5   *  •^  ■**    * 


JJ^^/f. 


/ 


^^^<:^^ 


A    TREATISE 

ON     THE 

DISEASES  OF  INFANTS, 

FOUNDED   ON   RECENT   CLINICAL    OBSERVATIONS   AND  INVESTIGATIONS   IN 

PATHOLOGICAL  ANATOMY, 

MADE    AT    THE    HOSPICE    DES    ENFANS-TROUVES : 

.        '  WITH   A 

DISSERTATION  ON  THE  VIABILITY  OF  THE  CHILD, 

BY 

C  .    M  .     B  I  LL  A  R  D  , 

\  '  Docteur  en  Mfidecine  de  la  Faculte  de  Paris,  etc.,  etc. 

WITH    NOTES 
BY  DR.  OLLIVIER,  OP  ANGERS. 

"  Vides,  ut  ampljssima,  eademque  propemodum  intentata  pateat  via  ad  recens  natorum  morbos  attenta, 
dum  vivunt  observatione,  accurata  autem  post  mortem  dissectione  pervestigandos,  nisi  parent um  inepta  ' 
rharjtas  obstaret."— (Moroagni,  de  sedibus  ct  causis  morborum.    Ep.  48,  p.  582,  ed.  Tissot.; 

SECOND    AMERICAN, 
TRANS  LA  TED    FROM    THE    THIRD    FRENCH    EDITION, 

WITH   AN   APPENDIX, 

BY 

JAMES   STEWART,   M.D. 

NEW-YORK: 

J.  &  H.  G.  LANGLEY,  57  CHATHAM  STREET  : 

PHILADELPHIA,  HASWELL,  BARRINGTON  &  HASWELL  : 
BOSTOTf,    WILLIAM    D.    TICRNOR. 

LONDON,  JOHN  CHURCHILL. 

:c^]?ccgxL. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1839;  by 

George   Adl ard, 

In  the  Clerk's  Office  of  the  District  Court  of  the  United  States,  for  the  Southern 

District  of  New  York. 


STEREOTYPED   BY   P.   F.   RIPLEY,   NEW  YORK. 


TO 


JOHN  W.  FRANCIS,   M.   D., 

LATE 

PROFESSOR    OF    OBSTETRICS,    DISEASES    OF    WOMEN    AND 
CHILDREN,    AND    OF    FORENSIC    MEDICINE, 

IN    THE 

COLLEGE  OF  PHYSICIANS  AND  SURGEONS 

OF   THE 

UNIVERSITY   OF   THE    STATE    OF    NEW    YORK, 

etc.,  etc.,  etc., 

THESE    PAGES 

ARE    RESPECTFULLY    DEDICATED, 

BY    HIS    OBLIGED    FRIEND, 

THE    TRANSLATOR. 


^  ^^^>fi 


CONTENTS. 


Translator's  Preface    . 
Preface  to  the  FirsC  Edition 
Introduction 


PART   I. 

Of  the  Phenomena  which  are  present- 
ed on  examining  externally  the  con- 
dition of  the.  Child      .         .         •  9 
Chapter  I. — Attitudes  of  the  Child  9 
Chapter  II.— Color  of  the  Skin       .  1^ 
Chapter  III. — Separation  ofjthe  Cord  15 
Chapter  IV. — Exfoliation  of  the  Ep- 
idermis        .         .         .         .  30 
Chapter  V. — Size   and   Weight  of 

the  Child        .        .        .        .35 
Chapter  VI. — Means  of  Expression 

.     of  the  Child        ...  38 
The  Cry  considered  with  reference 

to  Semeiology .        .        .        ;  38 

Expression  of  Face    .         .         .50 

Chapter  VII. — State  of  the  Pulse   .  54 

Chapter  VIIL— Feebleness  of  Birth  57 

X  PART  II. 

Diseases  of  Infants        .         .      '  .  61 

Chapter  I. — Piseases  of  the  Skin    .  62 
Section   I.  ■ —  Malformations    and 

Congenital  Diseases    .         .    .  62 
§  I.  Absence  of  the  Skin      .         .  63 
§  II.  Cutaneous  Excrescences     .  65 
§111.  Alterations  of  Color  ..         .  67 
§  IV.  Spots,  or  Noevi  Materni   .  69 
Section  II. — Diseases  of  the  Skin 
not    Inflammatory,    developed 
during  birth  or  after  that  pe- 
riod .     ■ 73 

§  I.  Ecchymoses         .         •         .  73 

§  II.  Tumors  of  the  Scalp    .         .  74 

§  III.  Bruises     ....  75 

§  IV.  Petechias      .         .         .  •      .  76 

Case  II.          .        .        .        .  76 
Section  III. — Inflammations  of  the 

Skin      • 78 

Case  III.        .         .        •         .  79 
Section  IV. — Inflammation  devel- 
oped after  Birth    .  .        .         .  80 
.     Table  first— Classes        .        .82 
■  Table  second — Genera       .        .84 
Table  third— Species       .        .  95 
Erythema       •        .        .        .        .95 


Case  IV.        ....        .        95 

Case  V. 96 

Erysipelas  .  .  •.  ,  .  98 
Measles          .         .        .        .      . .  101 

Roseola 103 

Scarlatina      .        .        •        .        .  104 
Urticaria    ......        .      106 

Blisters  .        .        .        .        .        .  108 

Ampulla 108 

Pemphigus    .         .         .        .        .108 

Case  VI 109 

Rupia  .  .  .  .  .  ,  111 
Zona,  or  Zoster  .  .  .112 
Herpes  .         .        .        .        .        .112 

Eczema 113 

Psora     .         .        .        .         .        .116 

Miliary  Sweat    .         .        .        .       117 

Variola,  Varicella,  Varioloid  .        .117 

Vaccinia 120 

Ecthyma        .        .        .        •        .121 

Acne 122 

Mentagra  .        ...        .        .122 

impetigo 123 

Tinea  Fovosa    ....       124 

"      Annularis  .        .        .         .'  127 

"      Granulata      .        .        .127 
"      Mucosa     .        .        .        .  127 

Prurigo      .        .        .        .        .      127 

Case  VII.  ...         .129 

Strophulus     .    .        .        .        .      130 

Lichen .         .         .        .        .         .132 

Cancer,  Lupus,  Elephantiasis     .      133 
Lepra    .        .         .        .        . .      .133 

Psoraisis    .         .        .        .        .      133 

Case  VIIL        .        .  "     .        .  134 

Pityriasis 136 

Fissures  .         .        .         .        ,136 

Malignant  Pustule,  Carbuncle  .  137 
Gangrene  of  New-born  Children  .  137 
Burns,  Chilblains  ..  .  .  138 
Diseases  of  the  Appendages  of  the 

Skin        .        .        .        .        .  139 
Diseases  of  the  Cellular  Tissue  .       140 
Inflammation  of  the  Cellular  Tis- 
sue     .        .        .        .        .      140 
CEdema^  or  Induration  of  the  Cel- 
lular Tissue    ...        .         .  141 
Chapter  II. —  Diseases  of  the  Di- 
gestive Apparatus        .        .       155 
Section  I. — Diseases  of  the  Mouth  156 
§  L  Malformations        .        .        .162 
Case  IX 162 


VI 


CONTENTS. 


§  II.  Passive  Congestions 
§  III,  Inflammations.     Stomatitis 
Erythematic  Stomatitis 
Stomatitis  with   altered   Secretion, 
or  Muguet      .... 
Follicular  Stomatitis  . 
Ulcerous  Stomatitis 

Case  X 

Case  XI.  .        . 
Pustular  Stomatitis     . 
Gangrenous  Stomatitis  . 

Case  XII 

Case  XIII 

Case  XIV 

§  IV.  Diseases  of  the  Parts  con- 
tained in  the  Mouth 
Section  II. — Development  and  Dis- 
eases of  first  Dentition 
Art.  1.  Development  of  the  Teeth 
Art.  2.  Anomalies  of  Dentition  . 
Art.  3.  Diseases  of  Dentition     . 

Case  XV 

Case  XVI 

Section  III — Diseases  of  the  Sali- 
vary Glands    .... 
Section  IV. — Diseases  of  the  Gut- 
tural Portion  of  the  Digestive 
Tube  ..... 
Sanguineous  Congestion  of  the  Or- 
gans of  Deglutition 
Inflammations    .... 

Case  XVII 

Case  XVIII. 

Case  XIX 

Section   V. — Diseases  of  the  CEso- 
phagus         .... 

Case  XX 

Case  XXI 

Diseases    of    the   CEsophagus  de- 
veloped after  birth   . 

Case  XXII 

Case  XXIII 

Case  XXIV. 

Case  XXV 

Case  XXVI. 
Case  XXVII.   ,         . 
Diseases  of  the  Sub-diaphragmatic 
Portion  of  the  Digestive  Tube 
Section  I. — Diseases  of  the  Stom- 
ach   developed    during    intra- 
uterine life  .... 
Case  XXVIII. 
Case  XXIX. 
Diseases  of  the  Stomach  developed 

after  birth 
Art.  1.  Gastric  Indigestion 
Art.  2.  Lesions   of   the    Stomach, 
Vfiih  or  without  disturbance  of 
its  functions    .... 
§  I.  Congestions  of  the  Stomach 

Case  XXX 

§  II.  Inflammations  of  the  Stomach 
Gastritis 


163 
163 
164 

164 
170 
179 

180 
180 

182 
182 
185 
186 
187 

192 

193 
193 

201 
203 
205 
206 

210 


211 

212 
213 
214 
216 
217 

219 
223 

224 

225 
226 
226 
227 
229 
230 
231 

236 


237 
239 
240 

242 
243 


247 
247 
248 
250 
250 


§  I.  Erythematic  Gastritis  . 

Case  XXXI.     .... 
§  II.  Gastritis,  with  altered  Secre- 
tion, or  Muguet  of  the  Stom- 
ach       

Case  XXXII 

Case  XXXIII.       . 
Case  XXXIV. 
§  III.  Follicular  Gastritis   , 
§  IV.  Gastritis,   with    disorganiza- 
tion of  Tissue 
Case  XXXV. 
Case  XXXVI. 
Case  XXXyil.     . 
Section  II. — Diseases  of  the  Intes- 
tinal Canal      .... 
§  I.  Development  of  the  Intestinal 


250 
252 


253 

254 
255 
257 
259 

261 
261 
264 
265 

270 

270 


Tube 
§  II.  Malformations  of  the  Intesti- 
nal Tube 
Case  XXXVIII. 
Case  XXXIX. 
Case  XL.       . 

Case  XLI 286 

Case  XLII 287 

Diseases  of  the    Intestinal   Tube 

developed  after  birth  .  .  288 
Art.  1.  Intestinal  Indigestion  .  289 
Art.  2.  Invagination  of  the  Intes- 
tines 
Art.  3.  Inflammation  of  the  Diges- 
tive Tube 
§  I.  Intestinal  Inflammation  during 

intra-uterine  life 
§  II.  Intestinal  Inflammation  devel- 
oped after  birth    . 

Case  XLIII 

Case  XLIV. 

Enteritis 

Case  XLV 

Case  XLVI 

Follicular  Enteritis 

Case  XLVII 

Case  XLVIII.       . 
Case  XLIX.     .         .         . 
Enteritis    with    disorganization    of 
Tissue 
Case  L.     . 
Art.  4.  Spasm  of  the  Intestines 


276 

278 
280 
281 


295 
296 

297 

299 
297 
298 
300 
301 
304 
305 
307 
309 
310 

312 
313 
320 


Art.  5.  White  Softening  of  the 
Gastro-intestinal  Mucous 

Membrane.        .        .        .323 

Case  LI 323 

Case  LII 325 

Art.  6.  Inquiry  into  the  principal 
Diseases  of  the  Intestinal  Ca- 
nal          327 

Chapter  III. — Diseases  of  the  Ap- 
pendages to  the  Intestinal  Ca- 
nal ...        .      332 
Section  I. — Development  and  Mal- 
formations of  the  Liver  .         .  332 
Section  //.—Diseases  of  the  Liver   333 


CONTENTS. 


Vll 


Chapter  IV. — Diseases  of  the  Uri- 
nary Apparatus   . 
Art.  1,  Development 

Case  LIII 

Case  LIV 

Chapter  V. — Peritonitis 

Case  LV 

Case  LVI 

Chapter  VI. — Ascites     . 
Chapter  VII. — Abdominal  Hernias 
Umbilical  Hernia 
Congenital  Inguinal  Hernia  . 

Case  LVII 

Prolapsus  of  the  Rectum 
Chapter  VIII. — Diseases  of  the  Res- 
piratory Apparatus 
Section  I. — Diseases  of  the  Nose 
and  Nasal  Fossse     . 
Case  LVIIL 

Case  LIX.         .         .         .         . 
Section  II. — Diseases  of  the  La- 
rynx and  Trachea 
Case  LX.  .... 

Inflammation  with   altered   Secre- 
tion or  Croup 
CEdematous  Afiection  of  the  Throat 
Case  LXI.         .         ,         .         . 
Section  III. — Diseases  of  the  Tho- 
racic Portion  of  the  Respira- 
tory Apparatus    . 

Case  LXII 

§  I.  Diseases  of  the  Pleura,  Lungs, 
and  Bronchise,  before  birth 
Case  LXIII. 
Case  LXI V.       . 
§  II.  Diseases  of  the  Lungs   and 
Pleiilra  developed  during  or  af- 
ter birth       .... 
Case  LXV.       . 


342 
342 
344 
345 
352 
353 
354 
357 
358 
359 
360 
361 
365 

366 

866 
371 
380 

375 

380 

382 
389 
389 


392 
395 

396 
397 
398 


Art.  1.  Congestions  and  Pulmona- 
ry Apoplexy 
Case  LXVI.      . 
Case  LXVII. 
Art.  2.  Pneumonia 
Case  LXVIII. 
Case  LXIX.     . 
Case  LXX.  . 
Case  LXXI.     . 
Case  LXXII. 
Art.  3.  Bronchitis . 

Case  LXXIII. 
Art.  4.  Pleurisy     . 
Case  LXXIV. 
Case  LXXV.  . 
Art.  6.  Hoopingcough 
Chapter  IX. — Diseases  of  the  Cir- 
culatory Apparatus 
Case  LXXVI.       ... 
Art.  1.  Establishment  of  Indepen- 
dent Circulation 
§  I.  Period  of  the  Obliteration  of 

the  Foetal  Openings    . 
§  II.  Mode  of  the  Obliteration  of 


399 
400 

402 
404 
404 
406 
407 
408 
409 
411 
412 
416 
416 
419 
419 
420 
424 

433 
434 

437 

437 


the  Foetal  Openings        .        .  440 
Art.  2.  §  I.  Diseases  of  the  Heart 

and  Large  Vessels       .        .      444 

Case  LXXVII.        .        .        .447 

Case  LXXVIII.   ...      448 

§  II.  Pericarditis    .        .        .         .450 

Chapter  X. — Diseases  of  the  Cere- 

bro-spinal  Apparatus       .        •      452 
Case  LXXIX.          .        .        .462 
Case  LXXX.        .        .        .471 
Art.  2.  Diseases    of  the  Cerebro- 
spinal Apparatus  developed  af- 
ter birth 472 

§  I.  Congestions         .        .         .      472 
§  II.  Softening       .         .        .         .474 
Case  LXXXI.      .        .        -474 
Art,  3.  Inflammation  of  the  Cere- 

bro- spinal  Apparatus        .        .  476 

§  I.  Spinal  Meningitis         .         .      477 

Case  LXXXII.     .        .        .477 

§  II.  Cerebral  Meningitis       •         .  478 

Case  LXXXIII.       .        .        .481 

§  III.  Inflammation  of  the  Spinal 

Marrow  and  Brain      .         .      484 
Case  LXXXIV.      .        .        .488 
Chapter  XI. — Diseases  of  the   Or- 
gans of  Locomotion     .        .      490 
Case  LXXXV.        -        .        .493 
Chapter  XII. — Diseases  of  the  Or- 
gans of  Generation      .         .      496 
Chapter  XIII.     Diseases     of 


Lymphatic  System  . 
Chapter  XIV. — Diseases 
Eyes 


the 
of     the 


499 


500 


Art.  1.  Development   and   Malfor- 
mations .         .         .        •         .  500 
Art.  2.  Ophthalmia  of  Infants   .      502 
Ch[apter  XV. — Jaundice    of  New- 
born Infants   ....  506 
Chapter  XVI. — Accidental  Tissues 

in  New-born  Infants   .         .       509 

Case  LXXXVI.       .        .        .509 

Chapter  XVII.— Alteration  of  Blood  512 


Medico-legal  Dissertation  on  Vi- 
ability, with  reference  to  the 
Pathology  of  New-born  Chil- 
dren     B15 

PART   I. 

Malformation  and  Congenital  Disea- 
ses ......  516 

§  I.  Malformation  and  Diseases 

of  the  Skin  .        .        .      516 

§  II.  Digestive  Apparatus      .        .  518 

§  III.  Urinary  Apparatus  .        .      523 

§  IV.  Peritonitis    .         .        .        .524 

§  V.  Abdominal  Hernias  .  .  525 
§  VI.  Respiratory  Apparatus  .  525 
§  VII.  Circulatory  Apparatus    .      530 


Vlll 


CONTENTS. 


§  VIII.  Cerebro-spinal  Apparatus 
Case .        .        .        .1 
Case       .        . 

PART  II. 

Medico-legal  Inductions    . 

Table  of  Congenital  Diseases     . 

Order- 1. — Malforjuations  and  Disea- 
ses necessarily  mortal 

Order  II. — Diseases  which,  without 
being  necessarily  mortal,  may 
oppose  the  development  of  In- 
dependent Life    .         .'        . 

Order  III. — Diseases  not  affecting 
Viability         .        .         .        . 


Appendix     .        .        . 
Separation  of  the  Cord 
Hemorrhage  from  the  Cord 


532 
535 
537 


540 
542 

542 


543 
544 


547 
547 

547 


Size  and  Weight  of  New-born  Chil- 
dren      .        .  .  •  .       . .        .  548 

Monstrosity   ...        .        ,     -550 

Congenital  Smallpox         .        .        .  551 
Erysipelas      .        .         .    .     •         .551 

Measles     .         .         .         •         .         .553 
Scarlet  Fever         .        .        .        .    .  555 

Acarus  Scabei,  or  Itch  Insect    .        ;  568 
Vaccinia        .        .         .        .        .      568 

Aphthae     .        .        .        .        ...  569 

Gangrene  of  the  Mouth         .        .      570 

Edentula 570 

Teething  .....  571 
Bloodletting  .  .  .  .  .  573 
Occlusion  of  the  Rectum  .  .  577 
Colic  .  :  .-  .'..•.  .578 
Functional  Disorders  of  the  Liver  579 
Hepatic  Affections  —  Bilious  Diar- 
rhoea— ^  Cholera  Infantum  .  580 
Cholera  Infantum  .  '  .  .  •  ..  587 
Suspension  and  RetentioA  of  Urine  593 
Croup  .  .  .  .  -  .  .594 
Hoopingcough  .  .  .  .  .  599 
Meningitis — Hydrocephalus  .  .  600 
Viability   .        .        ..       .        .        .601 


TRANSLATOR'S    PREFACE. 


The  progress  which  has  been  made  in  medical  science  by  the 
labors  of  those  who  have  devoted  themselves  to  the  investigations 
of  the  various  parts  of  the  human  body  in  disease,  will  distinguish 
the  present  age,  above  all  others  that  have  preceded  it,  as  a  period 
of  accurate  observation,  and  of  great  utility  in  medicine.  Anatomy, 
formerly  cultivated  only  as  preliminary  to  the  study  of  surgery,  has 
of  late  been  made  to  subserve  the  interests  of  practical  medicine;  and 
it  is  obvious  that  a  knowledge  of  the  various  structures  and  func- 
tions in  a  healthy  state,  and  the  alterations  they  undergo  in  disease, 
must  be  of  great  importance  in  assisting  the  practitioner  in  the  exer- 
cise of  a  proper  discrimination  in  any  departure  from  health,  and  that 
it  is  from  anatomical  and  pathological  science  alone  that  a  conception 
of  the  changes  which  occur  in  the  various  tissues  from  altered  action 
can  be  obtained.  The  substantial  truths  thus  accumulated,  united 
as  they  should  always  be  with  a  close  observation  of  symptoms, 
constitute  the  amount  of  our  knowledge  of  morbid  affections. 

The  pursuit  of  these  objects  needs  an  interest  in  science,  a  self- 
devotion  and  zeal,  of  no  ordinary  character.  To  study  the  intricate 
parts  of  the  wonderful  structure  of  man, — to  investigate  their  peculiar 
relation  to  each  other,  and  their  adaptation  to  the  purposes  for  which 
they  were  formed,  is  an  occupation  of  pleasure,  as  well  as  a  source  of 
instru)>^ion ;  but  to  extend  the  investigation  of  minute  anatomy  in 
tracing  the  insidious  progress  of  disease  through  each  tissue, — to  de- 
vote months  and  even  years  to  the  toil  arising  from  the  necessary  mul- 
tiplication of  objects  of  research,  must  be  attended  with  much  per- 
sonal privation,  and  demands  an  ardent  love  for  science,  commensu- 
rate only  with  the  importance  and  magnitude  of  the  objects  sought. 

Among  the  many,  in  every  country  where  science  is  cultivated, 
who  have  been  thus  engaged  in  serving  the  interests  of  humanity 
in  the  improvement  of  the  healing  art,  there  are  none  who  have 
enjoyed  better  opportunities  of  pursuing  these  studies  than  the 
French  pathological  anatomists  ;  and  it  must  be  conceded  that  none 
could  have  surpassed  them  in  diligence.  From  the  time  that  Bichat 
first  applied  himself  to  his  researches  in  the  minute  anatomy  of  dis- 
eased parts,  investigations  in  pathology  have  been  pursued  with  a 
zeal  unsurpassed  at  any  former  period,  and  to  the  labors  of  the 
French  pathologists  are  the  medical  world  indebted  for  the  posses- 
sion of  many  important  and  interesting  facts  illustrative  of  the  pro- 
gress and  effects  of  diseased  action. 


2  translator's  preface. 

In  this  class  of  contributors  to  science  is  the  author  of  the  follow- 
ing pages,  and  their  perusal  will  show  that  he  has  not  been  less  per- 
severing in  his  researches  than  his  predecessors.  The  field  chosen 
by  him  is  new,  not  having  heretofore  received  the  attention  of  any 
who  have  occupied  themselves  in  the  investigations  of  pathological 
truths.  While  the  fact  that  each  texture  possesses,  equally  with  its 
particular  species  of  vitality,  its  own  peculiar  diseased  action,  has 
been  proved  by  others,  he  has  shown  that  the  period  of  life  exercises 
also  an  important  influence  in  the  development  of  morbid  aflection. 
The  application  of  these  discoveries  must  undoubtedly  be  of  great 
practical  benefit  to  medicine. 

In  addition  to  pathology,  another  object  of  the  author  is  to  add 
something  to  the  stock  of  legal  medicine.  Too  implicit  a  reliance 
in  a  legal  question  on  any  one  appearance  of  the  body  of  a  child, 
however  unerring  the  inferences  may  have  sometimes  been,  will  often 
lead  to  error,  from  circumstances  arising  that  lessen  the  value  of  the 
appearances  which  various  parts  exhibit.  The  discovery,  therefore, 
of  new  facts,  and  by  their  assemblage  and  joint  concurrence  to  re- 
move all.  causes  of  fallacy,  is  a  desideratum  with  all  medical  jurists, 
and  is  only  to  be  attained  by  diligent,. close,  and  continually-extended 
observation;  and  it  is  the  mutual  relation  thus  ascertained  which 
alone  will  arrest  the  fluctuating  opinions  of  medical  witnesses,  and 
give  some  degree  of  certainty  to  medical  evidence.  In  this  depart- 
ment, the  author  has  detailed  a  number  of  interesting  facts,  with  ad- 
mirable discrimination  and  a  happy  clearness  of  illustration.  For 
the  additional  remarks  on  this  subject,  the  translator  is  indebted  to 
Dr.  John  W.  Francis,  late  Professor  of  Forensic  Medicine,  who, 
with  his  characteristic  kindness,  cheerfully  complied  with. the  request 
for  permission  to  record  in  the  appendix  his  experience  and  opinions 
on  a  matter  of  so  interesting  a  nature. 

The  great  number  of  cases  which  the  author  has  submitted  to 
examination, — his  careful  discrimination  of  the  various  appearances 
on  dissection, — his  separation  of  complicated  cases  from  those  in 
which  the  disease  under  consideration  appeared  unmixed,  that  the 
detail  of  symptoms  might  be  a  clear  indication  of  the  anatomical 
changes, — make  this  work  a  valuable  pathological  record  for  the 
practitioner ;  while  from  the  many  novel  facts  it  contains  connected 
with  the  subject  of  infanticide,  it  will  be  found  to  be  equally  valuable 
as  an  addition  to  the  library  of  the  student  of  medical  jurisprudence. 
New-York,  September,  1839. 


PREFACE  TO  THE   FIRST  EDITION. 


One  day  in  reading  Morgagni,  a  favorite  author  of  mine,  I  was 
particularly  struck  with  a  passage  in  the  latter  part  of  his  forty- 
eighth  epistle.  This  distinguished  observer,  after  havuig  enumer- 
ated the  affections  to  which  new-born  children  are  liable,  complains 
of  the  little  progress  that  has  been  made  in  their  pathology,  and 
laments  with  much  feeling  that  mothers,  from  a  false  tenderness, 
constantly  oppose  the  examination  of  the  bodies  of  their  children, 
the  symptoms  of  whose  diseases  may  have  been  watched  with  great 
carefulness  and  attention.  *'  How  vast  and  new,"  says  he,  "  is  the 
space  that  is  still  open  before  us  for  the  study  of  the  diseases  of 
young  children  !" 

From  Morgagni's  day  to  the  present  time,  the  subject  has  received 
the  attention  of  men  much  more  capable  than  myself,  of  extending 
the  boimdaries  of  science,  and  when  I  engage  after  them  in  the  same 
course,  T  do  not  pretend  to  accomplish  more,  or  to  go  further,  but 
only  to  glean  the  facts  which  have  escaped  their  notice,  and  to  unite 
with  their  discoveries  some  more  recently-ascertained  truths,  per- 
suaded that  in  thus  bringing  together  the  facts  scattered  throughout 
the  various  departments  of  science,  I  shall  be  able  to  render  some 
service  to  humanity. 

Occupying  for  a  year  an  important  station  in  the  Hospice  des  En- 
fans  Trouves,  in  Paris,  1  observed  with  close  attention  the  children 
in  that  institution,  and  upon  the  occurrence  of  a  fatal  termination  of 
their  diseases,  I  availed  myself  of  the  opportunity  thus  afforded  to 
examine  by  dissection  all  their  organs,  and  ascertain  the  causes  and 
seat  of  each  disease.  In  this  manner  has  the  wish  of  Morgagni  been 
fulfilled.  I  have  been  able  by  these  means  to  compare,  the  symp- 
toms observed  during  life  with  the  anatomical  lesions  by  which  they 
have  been  produced. 

The  principal  object  of  this  work  is  to  exhibit  the  peculiar  char- 
acter of  infantile  diseases,  and  to  consider  them  in  relation  to  the 


4  PREFACE    TO    THE    FIRST    EDITION. 

alterations  which  the  organs  have  undergone.  Each  system  has 
passed  successively  in  review^  and  I  have  studied  the  varieties  of 
form  and  appearance  of  every  organ,  with  reference  to  its  healthy, 
abnormal,  and  pathological  condition,  and  it  was  not  until  the  value 
of  the  symptoms  was  estimated,  and  the  nature  of  the  anatomical 
lesions  duly  considered,  that  I  finally  ventured  to  suggest  the  method 
of  treatment. 

I  have  considered  as  briefly  as  possible  the  development  of  the 
organs,  and  without  deeming  it  advisable  to  devote  much  attention 
to  congenital  malformations,  I  have  particularly  noted  those  which 
have  been  productive  of  some  symptom  during  life,  and  which  have 
thereby  disturbed  the  various  functions  of  the  child. 

I  have  neither  treated  of  fevers,  intestinal  worms,  nor  the  diseases 
of  the  lymphatic  system  in  particular,  because  they  are  of  rare  oc- 
currence in  new-born  and  sucking  infants, — to  which  class  of  chil- 
dren I  have  confined  my  attention, — but  belong  more  especially  to 
the  period  of  second  infancy  or  to  the  second  epoch  of  first  infancy. 
The  absence  of  all  febrile  reaction  in  young  infants,  when  at  the 
same  time  there  exist  serious  lesions,  and  the  readiness  on  the  con- 
trary with  which  fever  is  excited  by  the  slightest  cause  in  those  who 
are  teething,  impress  on  these  two  periods  an  important  difierence  in 
the  character  of  their  diseases. 

The  subjects  considered  in  this  work  being  of  considerable  ex- 
tent, I  have  used  as  much  conciseness  as  possible  in  the  history  of 
each  disease,  and  all  discussions  not  susceptible  of  elucidation  by 
facts  have  been  avoided,  and  speculative  theories  altogether  rejected. 

Finally,  I  have  written  this  work  with  the  independence  of  one 
who  would  not  draw  from  existing  doctrines  any  thing,  however 
positive,  the  truth  of  which  could  not  be  proved  by  established  facts, 
or  by  natural  analogy.  In  this  I  have  but  imitated  the  great  number 
of  those  who  have  cultivated  science  at  the  present  day.  This  essay, 
then,  carries  with  it  the  impress  of  the  age  and  the  spirit  of  con- 
temporaneous philosophy. 
Paris,  April,  1828. 


INTRODUCTION. 


When  any  branch  of  the  science  of  organization  is  to  be  studied, 
the  grand  principles  that  appear  to  direct  the  operations  of  nature, 
and  which  the  labors  of  learned  men  of  the  present  day  have  enabled 
us  in  some  degree  to  understand,  ought  in  the  first  place  to  be 
diligently  sought.  These  principles,  the  true  fundamentals  of  sci- 
ence, should  serve  as  a  base — as  a  point  of  departure — and  around 
them  it  is  our  duty  to  gather  the  results  of  our  labors  and  discoveries  ; 
for  it  is  such  an  assemblage  that  constitutes  the  philosophy  of  sci- 
ence, and  without  which  the  thoughts  advance,  destitute  of  a  guide 
or  an  object,  in  the  midst  of  the  theories  and  hypotheses  that  fill  the 
history  of  the  researches  of  the  human  mind.  Thus,  analysis  and 
synthesis  have  led  us  to  regard  as  well  established  the  following 
truths  relating  to  the  task  we  have  undertaken  : 

A.  From  the  moment  that  two  or  more  substances  are  united  in  such 
a  mannei^as  to  form  a  body,  for  the  preservation  of  which  the  gen- 
eral laws  of  nature  exercise  their  control,  this  body  enjoys  properties 
and  exhibits  phenomena  which  are  peculiar  to  it,  and  which  depend 
on  its  structure  and  organization.  In  the  mineral  or  inorganic  king- 
dom, crystals  and  salts  exist,  the  result  of  affinity,  and  of  the  attrac- 
tion of  aggregation  between  a  determinate  number  of  different  atoms  ; 
and  these  binary  or  ternary  compounds,  with  physical  and  chemical 
properties,  are  so  peculiar  to  the  composition  of  the  body  to  which 
they  belong,  that  these  qualities  will  necessarily  be  modified,  if  any 
change  is  produced  in  the  intimate  composition  of  the  body. 

B.  The  same  occurs  in  the  organic  kingdom  :  the  structure  of 
vegetables  embraces  also  the  condition  of  their  qualities,  and  the 
changes  in  the  nutrition,  composition,  and  ultimately  in  the  taste  of 
the  fruit  produced  by  the  soil  and  climate,  are  very  remarkable 
modifications  ;  so  true  is  it  that  their  qualities  and  properties  are 
immediately  dependant  on  the  structure  and  organization. 

C.  What  we  have  said  with  respect  to  vegetables  is  also  applicable 


b  INTRODUCTION. 

to  the  animal  kingdom.  It  is  well  known  that  the  form,  functions, 
and  peculiar  constitution  of  animals  depend  on  their  organization,  and 
the  varieties  presented  by  the  infusoria,  the  molusca,  the  vertebrata, 
and  mammalia,  are  well  known.  If  this  proposition  is  true  with  regard 
to  the  different  classes  of  organic  bodies,  it  is  also  true  with  regard 
to  the  different  individuals  of  the  same  class,  or  the  same  species, 
considered  in  the  various  changes  occurring  in  their  development. 
Thus  the  human  ovum  some  days  after  conception  differs  greatly 
from  the  foetus,  the  full-born  infant,  and  the  adult ;  by  reason  of  the 
actual  condition  in  which  the  materials  entering  into  its  composition 
reciprocally  exist.  The  labors  of  anatomists  go  entirely  to  the  sup- 
port of  this  proposition,  which  is  nothing  more  than  a  result  of  the 
general  principles  previously  exposed ;  and  we  ought  not  to  regard 
it  as  a  preconceived  principle,  but  as  a  general  rule  established  at 
this  time  from  the  knowledge  of  truth. 

D.  We  find  ourselves  now  ready  to  establish  a  priori  another 
principle  that  will  be  abundantly  confirmed  in  the  following  pages, 
but  which  it  is  important  at  this  time  to  advance,  that  the  spirit  in 
which  this  work  is  composed  may  be  known.  It  is,  that  if  all  the 
functions  of  living,  organized  bodies,  or  rather,  if  the  manner  in 
which  these  functions  are  performed,  be  found  in  dependance  on  the 
organization,  the  alteration  of  the  functions,  or  the  diseases  resulting 
from  any  disturbance  in  the  organs,  vary  equally,  according  to  the 
different  subjects  affected,  and  according  to  the  different  epochs  in 
the  life  of  the  same  subject. 

Thus,  in  proportion  as  the  ovum,  the  embryo,  the  foetus,  and  the 
adult,  become  more  perfect  in  their  organization,  their  functions  un- 
dergo a  peculiar  change  in  a  state  of  health,  and  likewise  present 
corresponding  peculiarities  of  symptoms  in  disease,  the  forms  of 
which  will  change  according  to  these  different  phases  of  organization. 
The  embryo,  being  but  a  simple  mass  of  cellular  tissue  and  mucus, 
dries  like  a  leaf  from  a  tree,  when  any  accidental  cause  detaches  it 
from  the  body  from  which  it  derived  its  support.  Furnished  at  a 
later  period  with  an  external  covering  and  an  internal  canal,  pro- 
vided also  with  circulatory  vessels  and  organs,  and  finally  changed 
into  a  sensible  and  moveable  body  ;  a  new  organization,  new  func- 
tions, and  new  symptoms  of  disease  inevitably  present  themselves  ; 
for  the  organization,  functions,  and  diseases  are  necessarily  con- 
nected with  each  other,  forming  a  succession  of  links,  the  whole  of 
which  constitutes  life,  considered  in  its  origin  and  development,  and 
also  in  its  normal  and  abnormal  state. 


INTRODUCTION.  7 

E.  From  these  considerations,  then,  it  appears  that  it  is  not  after 
birth  only,  as  has  been  asserted  by  philosophers,  that  man  for  the 
first  time  experiences  that  series  of  maladies  which  afflict  his  race, 
but  that  the  origin  must  be  sought  in  a  much  more  remote  source ; 
it  commences  with  the  organization  ;  and  the  annals  of  science  pre- 
sent at  this  day  a  number  of  facts,  which  attest  that  during  intra- 
uterine life  man  often  suffers  many  affections,  the  fatal  consequences 
of  which  are  brought  with  him  into  the  world.  We  can  here  ad- 
vance another  proposition  which,  already  established  by  facts  that 
are  daily  enriching  science,  will  receive  confirmation  by  the  observa- 
tions found  in  this  work  ;  it  is,  that  children  may  he  horn  healthy^ 
sick,  convalescent,  or  entirely  recovered  from  former  diseases. 
This  truth  is  of  great  practical  importance,  for  if  after  birth  children 
are  affected  with  diseases,  the  progress  of  which  is  not  interrupted  at 
the  period  of  birth,  but  on  the  contrary  the  diseases  continue  to  run 
their  course,  it  may  easily  be  conceived  how  important  it  is  for  the 
physician  to  be  able  to  recognize  the  external  signs  they  present,  in 
order  to  arrest  their  progress,  if  it  can  be  done.  On  thie  other  hand, 
if  it  happen  that  a  child  is  born  convalescent  from  a  disease  that  had 
existed  during  the  intra-uterine  life,  it  is  evident  again  that  great 
care  will  be  necessary  in  such  cases  to  protect  and  foster  the  wa- 
vering health  of  one  in  so  debilitated  a  condition.  And  if  the  child 
be  born  after  the  disappearance  of  disease,  the  physician  has  still 
a  taskxto  perform;  he  ought  under  such  circumstances  to  instruct 
the  parentis  in  the  best  method  of  restoring  vigor  to  the  exhausted 
constitution  ;  the  influence  of  a  proper  regimen  will  be  all  that  will 
be  necessary  to  enable  the  child  to  recover  the  energies  of  health. 

This  hasty  exposition  of  a  few  of  the  general  principles  established 
in  science  by  the  labors  of  those  who  have  devoted  themselves  to 
the  cause  of  truth,  will  give  us  some  idea  of  the  method  we  propose 
to  adopt  in  the  study  of  the  diseases  of  sucking  children  :  and  we 
will  endeavor  to  understand  their  peculiar  character,  the  better  to 
enable  us  to  facilitate  their  diagnosis,  a  subject  both  difficult  and 
obscure ;  at  the  same  time,  we  will  also  attempt  to  point  out  with 
care  such  affections  as  differ  from  those  of  more  advanced  age,  or 
bear  an  analogy  to  them. 

Before  entering  upon  the  study  of  particular  diseases,  it  will  be 
necessary  to  consider  the  general  phenomena  which  are  presented 
upon  examining  the  external  condition  of  the  child ;  this  will  be  the 
subject  of  the  first  part  of  this  work.  The  second  part  will  com- 
prise the  history  of  diseases  developed   both  during   intra-uterine 


8  INTRODUCTION. 

life  and  after  the  period  of  birth.  I  shall  study  these  diseases  ac- 
cording to  the  systems,  and  will  commence  always  with  an  examina- 
tion of  the  development  in  each  organ,  the  alteration  which  it  un- 
dergoes during  the  various  periods  of  its  formation,  and  with  the 
appearances  it  presents  in  a  state  of  health. 


A    . 

TREATISE 

ON 

THE    DISEASES    OF    INFANTS 


PART  I. 

OF   THE    PHENOMENA   WHICH    ARE    PRESENTED    UPON   EXAMIN- 
ING EXTERNALLY  THE  CONDITION  OF  THE  CHILD. 

Before  commencing  the  examination  of  the  particular  diseases 
of  the  organs,  it  may  be  useful  to  enter  upon  the  consideration 
of  such  subjects  as  present  themselves  to  the  observer  in  reference 
to  the  external  condition  of  newly  born  and  nursing  infants, 
the  period  of  life  to  which  we  propose  to  limit  our  researches. 
A  precise  knowledge  of  the  phenomena  which  are  exhibited 
upon  ^e  examination  of  the  child,  and  which  it  is  necessary 
to  consider  in  all  diseases,  such  as  the  expression  of  face,  crying, 
circulation,  etc.,  is  indispensable :  for  if  we  are  familiar  with  these 
in  a  state  of  health,  it  will  be  much  more  easy  for  us  to  appre- 
ciate the  modifications  they  undergo  in  disease.  On  this  account 
they  become  important  marks  of  comparison. 


CHAPTER    I. 

OF   THE    ATTITUDES    OF    THE    CHILD. 

If  the  child,  immediately  after  birth,  and  while  the  accoucheur 
is  engaged  in  tying  the  umbilical  cord,  be  allowed  to  remain  in 
the  situation  in  which  it  was  expelled  from  the  uterus,  it  will 


10  ON   THE    DISEASES    OP    INFANTS. 

be  observed  that  a  flexion  of  its  members  takes  place,  the  head 
and  the  breast  approximate,  the  body  rolls  upon  itself,  and 
assumes  a  posture  somewhat  similar  to  that  it  had  while  within 
the  womb.  When  the  child  is  separated,  it  attempts  to  stretch 
the  limbs,  and  will  toss  them  about  with  considerable  force;  but 
the  action  of  the  flexors  always  prevails  over  that  of  the  extensors ; 
the  limbs  therefore  bend,  the  hands  contract,  and  the  trunk  tends 
to  curve  forward ;  the  head  will  not  as  yet  obey  the  muscles 
appointed  to  preserve  it  in  its  erect  position,  and  it  moves  from 
side  to  side,  but  more  particularly  forward.  In  a  word,  the 
flexed  position  of  the  limbs  and  the  forward  curvature  of  the 
trunk,  constitute  the  peculiar  position  of  a  newly  born  infant. 

It  is  very  difficult  to  indicate  precisely,  the  different  periods  at 
which  an  infant  assumes  new  attitudes  ;  these  vary  according  to 
the  muscular  strength  or  weakness  of  each.  I  believe  also  that 
the  muscular  contractions  which  determine  the  attitudes  of  an 
infant,  being  under  the  influence  of  the  will,  become  evidences  of 
the  activity  of  the  sensorial  power,  and  that  the  brain  has  com- 
menced the  exercise  of  the  powers  to  which  it  is  destined.  All 
these  movements  are  at  first  purely  automatic  in  their  character. 
From  the  first  day  it  will  be  observed  to  grasp  at  every  thing 
around,  and  sometimes  seizing  them  mechanically  will  even  carry 
them  to  its  mouth.  Several  children  recently  born,  being  placed 
too^ether  on  a  bed,  I  observed  one  of  them  take  the  hand  of 
another,  and  completely  filling  the  mouth,  sucked  it  greedily ; 
a  movement  which  could  scarcely  be  attributed  to  the  exercise 
of  voluntary  power. 

But  in  proportion  as  the  child  advances  in  years,  it  exercises 
the  arms  and  hands  by  reaching  toward  the  objects  which  are 
within  its  grasp  ;  it  soon  avoids  such  as  are  not  agreeable,  and 
is  attracted  by  those  which  afford  pleasure,  and  they  are  thus 
made  instruments  of  repulsion  and  attraction  according  to  its 
desires  or  wants.  The  motions  of  the  superior  extremities  at 
first  purely  automatic,  soon  become  voluntary;  we  often  see  very 
young  infants  seize  with  eagerness  a  finger  or  a  coral  presented 
to  their  notice.  Almost  all  will  place  the  hand  in  that  of  the 
nurse ;  or,  introducing  one  or  more  fingers  into  the  mouth,  occupy 
themselves  with  sucking. 

To  the  voluntary  motions  of  the  arms  succeed  those  of  the 


ON  THE  DISEASES  OF    INFANTS.  11 

head ;  from  being  at  first  tottering,  it  becomes  fixed  upon  the 
neck.  In  proportion  as  the  faculty  of  vision  is  improved,  the 
motions  of  the  head  become  of  a  more  decided  character.  At 
the  age  of  a  month  the  infant  will  already  turn  its  head  on  the 
pillow,  either  to  the  right  hand  or  to  the  left,  when  a  brilUant 
object  is  brought  alternately  on  the  one  side  or  the  other.  At 
the  age  of  six  weeks,  he  fixes  his  attention  on  surrounding  objects, 
and  is  attracted  particularly  by  a  strong  light:  hence  the  well 
known  recommendation  to  prevent  a  ray  of  light  from  falling 
obliquely  upon  the  head  of  an  infant  in  the  cradle,  under  the 
apprehension  that  the  axis  of  vision  might  thereby  be  made  to 
deviate  from  the  natural  direction. 

At  six  weeks  or  two  months,  the  infant  scarcely  begins  to  have 
power  to  support  its  head,  but  is  constantly  to  be  seen  moving 
it  about  in  a  very  irregular  manner,  it  appears  too  heavy  for  the 
muscles  of  the  neck  to  direct  its  movement.  It  is  far  from  being 
useless  to  consider  these  matters,  for  they  serve  to  determine  the 
time  when  the  infant  may  be  carried  in  the  arms  without  the 
danger  of  suffering  from  fatigue.  We  are  of  opinion  that  the 
infant  ought  to  be  kept  in  a  horizontal  position,  or  carried  on  a 
pillow,  when  it  is  perceived  that  it  has  not  as  yet  sufficient 
muscular  strength  to  maintain  the  head  in  an  erect  position ;  in 
about  t\^o  months,  it  will  begin  to  have  power  sufficient  for  that 
purpose.  To  this  rule,  however,  there  are  many  exceptions^  at- 
tributable to  the  strength  or  weakness  of  different  individuals. 

The  vertebral  column  becoming  more  and  more  solid,  the  trunk 
sustains  itself  better,  and  at  the  age  of  four  or  five  months,  we  see 
the  infant  support  itself  in  sitting.  The  base  of  support  in  this 
position  is  between  the  hips,  the  spreading  of  which  is  constantly 
becoming  more  apparent.  Nothing  at  this  time  interferes  to 
prevent  the  infant  from  being  carried  about  in  the  arms.  The 
widening  of  the  hips  increasing,  the  sitting  posture  is  thus  ren- 
dered more  easy ;  and  at  the  age  of  seven  or  eight  months, 
infants  will  sit  up  in  their  cradles,  and  move  from  right  to  left, 
or  forwards  and  backwards,  with  the  greatest  facility.  We  may, 
therefore,  at  this  period  place  them  in  this  posture,  and  allow 
them  freely  such  exercise  as  they  are  capable  of  using. 

The  strength  and  movements  of  the  leg  are  developed  last 
of  all ;  and  about  the  eighth  or  ninth  month,  the  infant  essays 


12  ON  THE  DISEASES  OF  INFANTS. 

to  sustain  itself  upon  the  legs,  and  attempts  to  walk.     There  are 
many,  however,  who  do  not  walk  at  the  age  of  a  year. 

From  the  preceding  observations,  it  appears  that  the  flexed 
position  of  the  members,  and  the  forward  curvature  of  the  trunk, 
are  the  natural  attitudes  of  a  new-born  infant;  that  the  voluntary 
movements  arie  primarily  developed  in  the  superior  extremities  ; 
the  hand,  which  at  first  acts  only  mechanically,  becomes  more 
and  more  suited  to  its  uses,  under  the  direction  of  the  will. 

The  motions  of  the  head,  neck,  trunk,  and  lastly  of  the  inferior 
extremities,  follow  each  other  in  their  developments ;  so  that  the 
infant  gradually  emerges  from  its  inert  condition,  in  which  in- 
deed it  possessed  in  an  imperfect  state  all  its  motive  organs.  Man 
is  not  designed  by  nature  to  creep  on  all-fours,  as  has  been  main- 
tained by  some  philosophers ;  but  he  acquires  insensibly  the  power 
to  assume  the  attitudes,  and  to  exercise  all  the  motions  which 
characterize  the  individuals  of  his  species^  in  proportion  as  his 
body  becomes  more  perfect,  and  the  muscular  power  more  de- 
veloped. If  he  grasps  at  things  even  from  the  period  of  his  birth, 
it  is  because  the  clavicle,  humerus,  and  bones  of  the  fore-arm  are 
then  sufficiently  formed  for  that  purpose ;  while  the  pelvis,  on  the 
contrary,  being  quite  narrow,  and  almost  entirely  cartilaginous, 
affords  to  the  lower  extremities  no  point  of  support  of  sufficient 
solidity,  nor  to  the  trunk  a  base  large  enough  to  allow  of  stand- 
ing, much  less  of  walking.  Thus  we  find  all  the  functions  of 
the  system  becoming  developed,  perfected  or  altered,  in  connexion 
with  the  organization  upon  which  they  depend. 


CHAPTER  11. 


OF  THE  COLOR  OF  THE  SKIN. 


The  color  of  the  skin  equally  deserves  our  attention.  Infants 
recently  born,  are  almost  always  of  the  same  color.  Blood 
predominates  in  their  tissues,  and  communicates,  to  them  its  hue 


ON  THE  DISEASES  OF  INFANTS.  13 

and  the  face,  body,  and  limbs  are  all  strongly  colored.  From 
the  fifth  to  the  eighth  day  after  birth,  this  hue  diminishes,  .but 
will  in  some  cases  continue  a  longer  time ;  it  is  therefore  diffi- 
cult to  indicate  precisely  its  probable  duration.  This  red  color 
is  purely  accidentart,  and  upon  its  disappearance,  is  followed  by 
other  hues  of  various  character. 

If  it  continue,  it  is  not  so  intense  as  at  first ;  it  becomes  of  a 
violet  hue,  and  the  hands  and  feet  more  particularly  exhibit 
this  change  of  color.  The  alteration,  however,  is  not  always 
an  evidence  of  health,  for  it  often  co-exists  with  an  (Edematous 
swelUng  of  the  limbs.  We  will  return  hereafter  to  the  consider- 
ation of  this  violet  coloring,  and  to  the  subject  of  the  conges- 
tion of  the  integuments  of  new-born  children.  To  this  primi- 
tive sanguineous  color,  several  peculiar  hues  succeed.  The 
integuments  become  of  a  beautiful  rose,  of  a  remarkably  white, 
or  of  a  yellow,  more  or  less  deep. 

When  the  finger  is  applied  to  the  skin  of  an  infant,  the  red 
color  disappears  at  this  point,  and  it  becomes  yellowish ;  after- 
wards the  blood  returns  by  degrees  in  the  capillaries  from 
which  the  pressure  had  removed  it,  and  the  yellow  tint  is  re- 
placed by  the  previous  red.  It  will  often  be  observed,  after  the 
red  color  has  disappeared,  and  before  it  becomes  altogether 
white,  \l5at  the  skin  will  exhibit  a  universal  tint  of  yellow,  and 
sometimes  of  a  copper  color.  This  is  thought,  by  physicians 
generally,  to  indicate  an  affection  of  the  liver.  The  result  of 
our  observations  on  this  subject,  however,  will  justify  us  in 
controverting  this  opinion. 

We  can  easily  conceive  how  the  blood,  being  distributed  by 
the  organs  to  the  surface,  for  the  nourishment  of  the  integu- 
ments during  the  first  period  of  extra  Uterine  existence,  imparts 
to  the  surface  a  rosy  and  vermilion  hue,  while  at  the  same 
time  they  are  distended  by  firm  and  elastic  flesh.  This  is  an 
evidence  of  health  ;  and  it  is  remarked  by  the  least  observing, 
that  the  infant  is  in  sound  health  when  it  possesses  a  rosy  and 
soft  skin,  and  muscles  firm  and  elastic  to  the  touch..  This 
opinion  is  just,  although  there  are  exceptions.  The  skin  of  a 
new-born  child  is  covered  with  an  albuminous  paste,  more  or 
les?3  thick ;  and  a  viscous  humidity  remains  upon  it  for  some 
days,  particularly  in  the  folds,  often  causing  considerable  irri 


14  ON   THE    DISEASES   OF   INFANTS. 

tation.  The  slvin  soon  becomes  dry,  but  its  exhalation  exhi- 
bits nothing  remarkable. 

This  red  color  has  at  all  times  attracted  the  attention  of  phy- 
sicians. Van  Swieten,  in  his  Commentaries  on  the  Aphorisms 
of  Boerhaave,  says,  "  Haec  cutis  rubedo  aeque  manifesta  est  in 
^tiope  ac  in  Europoeo  et  vulgo  creditur  eo  nitidiorem  ac 
pulchriorem  cutem  futuram  postea,  quo  magis  rubicunda  fuerit 
in  recens  nato  infante." 

It  has  been  believed  that  the  general  redness  appears  only  in 
such  as  have  been  washed  in  warm  water,  in  order  to  remove 
the  sebaceous  matter  with  which  the  child  is  usually  covered ; 
but  I  have  observed  infants  exhibit  this  color  even  before  they 
were  washed ;  whence  I  conclude  that  it  is  more  reasonable  to 
attribute  it  to  the  superabundance  of  blood  in  the  integuments. 
I  cannot  believe  in  the  assertion  that  infants,  who  are  the  most 
red  at  the  birth,  will  afterwards  become  in  proportion  whiter. 
I  have  never  observed  any  thing  to  give  confirmation  to  this 
rule.  The  peculiar  hues  which  the  skin  afterwards  assumes, 
are  sometimes  influenced  by  light  or  temperature,  as  well  as 
by  the  place  of  residence.  Children  brought  up  in  large 
cities,  are  always  paler  than  those  living  in  the  country,  who 
are  constantly  exposed  to  the  rays  of  the  sun.  Besides  the  in- 
fluence of  temperature  and  of  climate,  peculiar  to  certain  coun- 
tries, various  colors  exist,  which  are  the  effect  of  a  peculiarity 
of  constitution.  About  the  end  of  the  third  month,  the  dis- 
tinctive color  becomes  established,  and  we  can  from  that  time 
distinguish  dark-complexioned  children  from  those  that  are  fair; 
at  a  much  more  tender  age  the  hair  has  already  assumed  its  pro- 
per hue  ;  but  it  is  not  until  the  period  of  which  we  are  speaking, 
that  the  skin  on  the  body  becomes  dark  or  light  colored,  the  face 
either  pale  or  ruddy,  and  the  traits  peculiar  to  each  constitution 
delineated.  It  is  true  that  a  great  number  of  external  causes  pro- 
duce modifications  in  the  constitution  and  temperaments  of 
children ;  I  only  observe,  that  it  is  at  the  age  of  two  or  three 
months  that  we  can  begin  to  discover  the  shades  of  color,  and 
the  prevailing  hue  of  each  infant.  As  the  child  advances  in  age 
these  differences  become  more  evident. 


ON   THE    DISEASES    OP    INFANTS.  15 


CHAPTER    III. 

OF   THE    SEPARATION   OF    THE    UMBILICAL    CORD. 

I  PROPOSE  now  to  consider  all  the  phenomena  which  precede, 
accompany,  and  follow,  the  separation  of  the  umbilical  cord. 
Notwithstanding  the  interesting  accounts  on  this  subject  con- 
tained in  the  numerous  treatises  on  midwifery,  and  legal  medicine, 
it  appears  to  me  that  there  still  exists  a  want  of  information  in 
reference  to  it ;  a  deficiency  which  I  propose  to  supply  by  detail- 
ing the  results  of  my  observations. 

§  I.  Of  the  desiccation  of  the  iimhilical  cord. — The  desiccation 
of  the  umbilical  cord,  and  the  time  of  its  separation  from  the 
abdomen,  differ  very  considerably  in  diiferent  individuals,  inso- 
much that  it  is  extremely  difficult  to  establish  in  relation  to  it  any 
fixed  rules.  In  order  to  be  familiar  with  these  varieties,  I  shall 
examine  particularly  the  subject  of  this  chapter,  and  compare 
the  inferences  made,  with  the  statements  of  those  authors  who 
have  preceded  me. 

My  ol^servations  have  been  directed  to  eighty-six  children  of 
different  ages  and  sexes,  all  apparently  in  good  health  :  and  in 
the  first  place  I  examined  particularly  the  two  well-marked  dif- 
ferences between  the  cords  which  have  been  pointed  out  by  ac- 
coucheurs. Some  umbilical  cords  are  large,  soft,  and  thick; 
these  contain,  according  to  Wharton,  a  great  deal  of  gelatine ; 
others  are  small  and  thin,  and  contain  very  little  albuminous  mat- 
ter. The  former  require  a  larger  time  to  dry  away  ;  they  have 
a  tendency  to  soften,  and  often  separate  at  the  base.  The 
latter  soon  become  dry  and  transparent  Uke  parchment,  they  de- 
siccate very  rapidly,  and  upon  becoming  quite  dry,  black  lines, 
the  remains  of  the  blood-vessels,  may  be  observed  in  their  tissue. 
About  one-third  of  the  whole  number  are  of  slender  kind,  the 
remainder  are  of  those  abounding  in  gelatinous  matter.  Before 
desiccation  they  shrink,  which  is  the  beginning  of  this  process. 
The  following  shows  the  results  of  my  observations  in  relation 
to  the  time  at  which  the  desiccation  commences. 


16  ON   THE    DISEASES   OF   INFANTS. 

Of  eighty-six  infants  who  came  under  my  notice,  the  cords  of 
sixteen  were  a  little  shrunk,  but  were  at  the  same  time  quite  fresh. 
They  were  soft,  bluish,  and  very  flexible,  and  completely  filled 
the  ligature;  the  cut  surface  was  quite  smooth.  Of  these 
sixteen,  one  was  of  the  age  of  five  hours,  six  of  one  day,  four  of 
two  days,  and  four  of  three  days.  These  cases  afforded  an  op- 
portunity of  observing  the  shrinking  of  the  cord  from  the  first 
to  the  third  day  after  birth.  But  it  does  not  always  follow  from 
this,  that  the  desiccation,  which  always  succeeds  the  shrinking, 
never  commences  until  after  the  third  day.  It  often  begins  much 
sooner,  as  we  shall  see  by  the  details  which  follow.  Among  the 
eighty-six  infants  whose  cases  we  are  now  considering,  there 
were  twenty-four  where  the  desiccation  had  either  commenced  at 
the  summit,  arrived  at  the  middle,  or  had  already  spread  near  the 
base  of  the  umbilical  cord.  Seven  were  but  of  the  age  of  one  day, 
eleven  of  two  days,  three  of  three  days,  and  three  of  four  days. 
Among  some,  the  cord  was  large  and  very  soft,  with  a  thick,  project- 
ing cutaneous  ring  at  the.base.  In  neither  of  them  did  the  extrem- 
ity exhibit  a  smooth  surface,  but  it  had  begun  to  blacken  and 
shrivel,  while  the  ligature  was  quite  loose  ;  in  the  greater  num- 
ber of  cases  there  had  been  no  inflammation  at  the  umbilicus.  By 
this  it  will  be  seen  that  the  desiccation  generally  begins  on  the 
first  or  second  day ;  it  has  sometimes,  however,  been  as  late  as 
the  fourth  day. 

The  period  of  the  complete  desiccation  of  the  cord  is  not  less 
variable.  Among  the  eighty-six  infants  to  whom  reference  has 
been  made  above,  there  were  twenty-five  where  the  cord  was 
perfectly  dry  ;  of  these,  five  were  of  the  age  of  two  days,  nine 
of  three  days,  five  of  five  days,  four  of  four  days,  one  of  one  day, 
and  one  of  one  day  and  a  half  The  third  day,  therefore,  appears 
to  be  the  usual  time  at  which  the  desiccation  of  the  umbilical 
cord  is  completed,  although  it  has  not  occurred  in  some  cases 
until  the  fourth  or  fifth  day ;  and,  as  we  have  seen,  been  even  as 
early  as  the  first  day.  But  it  ought  to  be  known  that  the  cords 
in  the  last  mentioned  cases  were  extremely  thin,  and  it  was  owing 
to  this  peculiarity  that  the  desiccation  was  hastened. 

Immediately  upon  cutting  the  cord  the  vessels  retract  and  dis- 
appear in  the  gelatine,  which  constitutes  so  large  a  part  of  the 
cord,  and  which  gives  to  it  its  form  and  thickness.    This  gelatine 


ON  THE    DISEASES   OP   INFANTS.  17 

begins  to  dry  away  even  while  the  exterior  membrane  retains  its 
suppleness.  It  is  not  always  at  the  summit  that  the  desiccation 
commencesj  for  it  often  exhibits  the  beginning  of  this  process  at 
the  place  where  the  ligature  remains  for  some  time  soft.  The 
cord  shrinks  and  shortens  ■  at  the  same  time,  a  general  constriction 
takes  place  from  the  circumference  to  the  centre,  whereby  the 
vessels  become  compressed,  flattened,  and  tortuous,  and  at  last 
partake  themselves  of  the  desiccation.  They  are  solidly  com- 
pressed in  the  thick  dried  lymph,  resisting  any  fLuiher  retraction, 
and  exhibit  small  black  opake  filaments,  winding  in  the  middle 
of  a  semi-transparent  substance.  At  this  period  the  ligature  is 
altogether  useless,  and  hemorrhage  from  the  extremity  of  the 
cord  need  not  be  apprehended. 

The  desiccation  progressing  by  degrees  towards  the  navel, 
stops  at  last  at  the  cutaneous  ring  at  the  root  of  the  cord,  from 
which  the  dried  portion  soon  becomes  separated,  either  by  a  proper 
suppuration,  or  by  a  spontaneous  detachment  analogous  to  that  by 
which  the  stem  of  a  cucurbitaceous  fruit  is  separated.  The 
dried  gelatine,  and  not  the  epidermis,  as  has  been  asserted,  forms 
around  the  three-fold  vascular  bundle,  a  kind  of  knot  which 
compresses  and  defends  the  walls  of  these  vessels.  There  exists 
always  between  this  point  of  constriction  and  the  place  where 
these  th'ree  umbilical  vessels  pass  to  their  destination,  a  space  or 
neck  more^or  less  short,  where  the  cord  consists  of  nothing  but 
a  little  vascular  bundle^  the  last  connexion  of  the  abdomen  with 
the  cord,  moving  in  every  direction  as  on  a  slender  pivot.  This 
vascular  line  is  entirely  surrounded  by  the  cutaneous  ring  of  the 
umbilicus,  upon  the  circumference  of  Which  the  separation  of 
the  cord  has  left  small  excoriations ;  it  does  not,  as  has  been 
asserted  by  Gardien,  produce  any  constriction  upon  the  um- 
bilical vessels.  The  skin  of  the  umbilicus  gathers  in  laro^e  folds 
when  the  base  of  the  cord  is  dried,  but  it  is  by  the  drawing  of 
the  hardened  gelatine,  and  when  the  separation  is  effected  around 
the  whole  circumferences,  that  the  skin  of  the  umbilicus  becomes 
thus  folded  upon  itself  This  condition  of  the  skin^  therefore,  is 
tlie  result,  and  not  the  cause  of  the  desiccation.  It  is  at  this 
point,  that  is  to  say,  at  the  point  where  the  gelatine  ceased  to  exist, 
that  the  cord  separates,  and  all  the  concurrent  circumstances 

then  favor  the  event ;  indeed^  even  the  crying  of  the  child,  pro- 

3 


18  ON   THE    DISEASES   OP   INFANTS. 

ducing  every"  moment  an  elevation  and  depression  of  the  dia- 
phragm and  hver,  and  causing  the  alternate  movements  of  ex- 
pansion and  retraction  of  the  parietes  of  the  abdomen,  materially 
assist  it ;  the  effect  produced,  being  a  continual  drawing  of  the 
umbilical  vessels  towards  the  interior  of  the  cavity  of  the  abdo- 
men, while  on  the  other  hand  the  external  dried  portion  of  the 
cord,  being  drawn  by  the  clothes  of  the  child  or  fixed  by  its  ap- 
propriate bandage,  resists  with  considerable  force  the  internal 
movements ;  the  cord,  yielding  at  its  slender  part  to  this  constant 
drawing,  separates  and  falls.  Thus  the  desiccation  is  the  predis- 
posing, and  the  pulling  of  the  cord  the  immediate  cause  of  its 
separation.  In  this  way  we  can  explain  how  it  happens  that  the 
cord  is  always  ruptured  at  the  same  place,  and  why  we  never  see 
it  detach  itself  at  the  abdomen  before  the  complete  desiccation  of 
the  gelatinous  matter.  The  desiccation  of  the  cord  is  altogether 
a  physiological  phenomenon,  belonging  to  the  assemblage  of 
vital  phenomena,  and  entirely  dependent  on  them.  That  part  of 
the  cord  attached  to  the  placenta  does  not  exhibit  the  phenome- 
non of  desiccation,  like  the  portion  remaining  with  the  child, 
but  shrinks  and  decays  like  a  dead  substance,  whilst  the  abdo- 
minal portion  is  not  so  affected.  Here  the  desiccation  ceases  as 
soon  as  life  is  extinct ;  it  either  does  not  proceed  in  still-born 
children,  or  it  is  considerably  retarded.  In  place  of  drying  and 
separating  at  the  end  of  a  few  days,  as  is  observed  during  life, 
the  cord  undergoes  in  the  dead  body  a  perfect  decomposition, 
differing  entirely  from  its  normal  desiccation.  We  often  see 
a  foetus  brought  into  the  theatre  for  dissection,  and  remain 
there  some  days  without  the  cord  becoming  dry ;  it  will  even 
continue  soft,  and  the  vessels  sufficiently  open  to  allow  of  being 
injected ;  while  during  life  it  dries,  and  the  vessels  are  obliterated 
on  the  first,  second,  and  third  days ;  and  I  have  never  seen  the 
cords  dry  away  at  first,  but  remaining  soft  and  flexible  until  the 
fourth  or  fifth  day,  when  they  often  separate  in  a  state  of  putres- 
cency.  I  have  been  able  to  inject  the  body  of  a  still-born  child 
from  the  umbilical  cord  at  the  end  of  four  days,  only  taking  the 
precaution  to  moisten  the  extremity,  which  had  become  a  little 
dry.  The  cord  did  not  exhibit  the  least  degree  of  desiccation, 
but  was  only  very  tender.  The  normal  desiccation  of  the  um- 
bilical cord  may  therefore  be  regarded  as  a  physiological  phe- 


ON  THE    DISEASES    OF    INFANTS.  19 

nomenon,  occurring  only  during  life,  and  ceasing  with  the  sus- 
pension of  vitality. 

The  following  cases  are  in  support  of  this  assertion  :— Three 
living  but  feeble  children,  born  at  one  birth  on  the  night  of  the 
20th  of  October,  were  brought  a  few  hours  after  to  the  Hospice 
des  Enfans  Trouves.  One  of  them  died  six  hours  after  birth ;  the 
cord  of  this  child  was  very  soft,  and  not  in  the  least  shrunk. 
Another  died  on  the  night  of  the  22d  ;  the  cord  of  this  one  was 
flattened,  twisted,  and  dried  about  half  its  length.  The  third 
died  on  the  morning  of  the  23d  ;  the  cord  of  this  child  was  dry 
nearly  the  whole  length.  In  neither  of  these  cases  was  there 
red  circles  around  the  umbilicus.  The  first  mentioned  child 
was  carefully  preserved  in  an  envelope  ;  and  on  the  24th  the 
cord  had  not  yet  showed  any  signs  of  desiccation,  but  was  only 
a  little  shrunk.  The  desiccation  of  the  cord  was  not  at  all 
effected  in  this  case,  death  having  entirely  prevented  its  occur- 
rence, whilst  in  the  two  that  survived,  the  phenomenon  was  ob- 
served to  commence  and  to  run  its  course  until  arrested  by  death. 

Without  attempting  to  explain  how  this  phenomenon,  which 
appears  to  be  altogether  physical,  is  so  intimately  connected  with 
life,  I  will  merely  remark,  that  the  animal  heat,  which,  during 
the  life  of  the  child,  is  communicated  to  the  cord,  favors  very  ma- 
terially tjie  evaporation  and  drying  of  the  gelatine  of  Wharton, 
and  that  the  moisture  which  exhales  from  the  dead  body,  keeps 
the  gelatine  soft,  or  hastens  its  decomposition  ;  whether  this  be 
the  case  or  not,  the  fact  exists,  and  it  appears  to  me  proper  to 
keep  it  in  remembrance,  from  its  important  application  to  legal 
medicine.  For  if  a  foetus  be  examined  some  time  after  birth, 
or  when  the  body  has  been  disinterred,  if  the  cord  still  remain 
attached,  we  ought  to  observe  closely  if  it  exhibits  the  peculiar 
characteristic  of  a  normal  desiccation  ;  that  is  to  say,  whether  it 
is  red,  flattened,  and  twisted,  and  the  vessels  obliterated^;  or 
whether  it  is  soft  or  in  a  state  of  putrefaction,  analogous  to  the 
general  condition  of  the  dead  body ;  for  in  the  former  case,  the 
child  could  not  have  been  still-born,  but  might  have  lived  one 
or  two  days,  since  the  desiccation,  which  only  exists  during  life, 
had  already  commenced,  while  in  the  latter,  the  infant  was  still- 
born, or  had  lived  but  a  short  time  ;  the  umbilical  cord  flabby  or 
slightly  shrunk,  having  not  yet  experienced  the  proper  desicca- 


20  ON    THE    DISEASES    OF    INFANTS. 

tion.  In  short,  snch  is  the  importance  of  the  fact,  that  I  would 
particularly  call  the  attention  of  physicians  to  its  consideration, 
that  it  may,  in  conjunction  with  other  circumstances,  concur  in 
demonstrating  whether  the  child  was  born  alive  ;  as  the  prniciple 
can  be  laid  down  that  in  every  instance  in  which  the  cord  is 
dried,  flattened,  twisted,  and  blackened  upon  the  dead  body  of  an 
infant,  it  has  lived  at  least  one  day,  this  condition  never  being 
produced  on  a  dead  body.  To  recapitulate ;  the  conclusions  appli- 
cable  to  legal  medicine  upon  examining  the  umbilical  cord  be- 
fore  its  separation,  are  :  1st.  The  desiccation  of  the  umbilical 
cord  cannot  take  place  except  during  life.  2d.  At  the  period  of 
death,  the  desiccation  is  suspended,  or  considerably  retarded. 
3d.  If  the  cord  be  fresh,  or  the  shrinking  but  just  commenced, 
the  infant  may  have  been  still-born,  or  have  lived  but  a  very 
short  time.  4th.  If  the  cord  has  already  exhibited  the  beginning 
of  desiccation,  or  is  completely  dry,  the  infant  has  lived  at  least 
one  day.  The  more  recent  the  death  of  the  foetus,  the  greater 
is  the  dependence  upon  these  conclusions. 

When  the  cord  is  left  to  putrefy  upon  the  dead  body,  it  first 
assumes  a  greenish  white  color ;  it  then  becomes  corrugated  at 
the  extremity,  and  shrinks.  The  pellicle  of  the  cord  is  easily  de- 
tached, but  the  cord  will  not  separate  from  the  abdomen  at  its 
point  of  insertion,  as  is  observed  to  be  the  case  during  life ;  it 
may  easily  be  torn  in  all  places,  and  lessens  and  withers  its 
whole  length,  and  if  the  child  has  been  immersed  a  long  time  in 
water,  it  remains  flabby  and  tender ;  the  same  thing  occurs  when 
the  child  is  dead,  and  has  remained  some  time  in  the  waters  of  the 
amnios.  In  the  opposite  case,  it  exhibits  much  more  resistance, 
and  less  softness,  and  the  umbilical  vessels  which  perform  the  office, 
as  we  may  say,  of  a  root,  will  constantly  oppose  a  considerable 
degree  of  resistance  to  the  force  which  may  be  used  to  break  it.  I 
have  never  seen  the  cord  of  a  still-born  child  become  dry  before  the 
fifth  or  sixth  day,  and  have  also  observed,  that  it  preserves  its  cir- 
cular form  and  suppleness  for  some  days.  Dr.  Ollivier,  of  Angers, 
has  favored  me  with  a  very  interesting  communication  on  this 
subject.  He  was  called  on  the  28th  of  September,  1826,  with 
Messrs.  Marc  and  Denis,  to  examine  at  the  morgue,  the  dead 
body  of  a  male  child,  born  at  the  full  time,  having  been  eight  or 
nine  days  dead.    All  its  parts  were  reduced  to  a  state  of  complete 


ON    THK    DISEASES    OP    INFANTS.  21 

putrefaction,  the  cavities  were  distended  with  gas,  the  substance 
of  the  kings  was  completely  putrid,  and  the  umbilical  cord,  which 
appeared  not  to  have  been  tied,  itself  partook  of  the  general  de- 
composition of  the  body.  Its  length  was  about  four  inches,  and 
near  the  umbilical  ring,  the  envelope  of  the  cord  was  simply  a 
thin  pellicle,  through  which  the  umbilical  vessels  could  be  seen ; 
and  in  the  place  of  being  dr)^,  flattened,  and  twisted,  as  is  usual  • 
ly  the  case,  it  had  formed  a  puckered  sack  at  the  extremity ;  in 
the  interior  of  which,  the  gelatine  of  Wharton  had  disappeared ; 
this  sack  resembled  a  membranous  case,  with  transparent  walls, 
analogous  to  a  portion  of  intestine,  distended  with  air  and  dried. 
The  epidermis  upon  the  abdomen  was  removed  as  soon  as  it 
was  touched,  and  yet  the  membrane  of  the  cord,  and  the  cord 
itself,  was  firmly  adherent.  We  ought  not  to  confound  this  con- 
dition with  the  proper  desiccation  of  the  cord,  it  having,  in  the 
instance  before  us,  undergone  a  real  decomposition,  not  produ- 
cing its  separation,  because  the  circumstances  which  effect  this 
during  life,  had  not  existed.  I  have  remarked  in  general, 
that  the  putrefaction  of  the  cord  does  not  commence  until  after 
the  decomposition  of  the  other  parts  of  the  body,  so  that  it  is 
never  found  putrefied,  unless  the  walls  of  the  abdomen  are  green, 
and  all  the  parts  of  the  body  evidently  in  a  state  of  putrefaction. 
§  11.  Separation  of  the  umbilical  cord. — This  phenomenon  is 
explained  in  different  ways.  Haller  and  Munroe  attributed  it  to  a 
kind  of  gangrene;  and  the  celebrated  physiologist  of  Berne, 
explains  it  in  the  following  manner.  "  Funiculi  quidem  ombili- 
calis  particula  quam  obstetrices  solent  cum  abdomine  parvuli 
conjunctam  relinquere  abit  in  sphacelam,  quassi  ambusta  et  post 
biduum,triduumve  dilabitur."  This  opinion  has  been  maintain- 
ed by  a  great  number  of  physiologists.  Other  explanations  have 
been  given  in  relation  to  this  phenomenon.  M.  Gardien  regards 
the  constriction  of  the  epidermis  as  the  cause  of  the  separation. 
Chaussier  attributes  it  to  an  inflammatory  action,  developed  at  the 
umbilicus  ;  this  opinion  is  also  adopted  by  Beclard,  professor  Or- 
fila,  and  M.  Capuron.  And  lastly.  Dr.  Denis,  who  has  made  upon 
this  subject  some  interesting  researches,  asserts,  that  during  the 
process  of  desiccation,  the  masceration  of  the  base  of  the  cord, 
by  a  mucous  secretion,  the  retiring  of  the  skin,  and  the  putrid 
dissolution  of  the  substance  of  Wharton,  produce  by  degrees  the 


22  ON   THE    DISEASES    OF    INFANTS. 

separation  of  the  cord.  These  physicians  have  observed  a  kind 
of  separation  at  the  base  of  the  cord,  under  circumstances  which 
we  will  hereafter  notice  more  particularly;  it  is,  however,  not 
constant,  but,  as  will  be  shown,  is  purely  accidental.  As  to  the 
opinion  of  Haller,  it  falls  of  itself  Let  us  admit  then,  for  the 
present,  the  explanation  we  have  given  of  the  separation  of  the 
cord,  and  proceed  to  examine  the  facts  which  support  the  asser- 
tion. 

The  period  of  the  separation  varies  very  materially.  Among 
the  number  of  infants  mentioned  above,  there  were  twenty-one 
where  the  cord  had  separated,  but  in  only  sixteen  of  these,  was 
it  of  recent  occurrence.  There  were  two  in  which  the  cord 
separated  on  the  second  day,  three  on  the  third,  six  on  the  fourth, 
three  on  the  fifth,  one  on  the  sixth,  one  on  the  seventh  day — 
the  cord  of  the  last  child  fell  in  my  hands  while  I  was  making 
an  examination — and  one  on  the  ninth  day.  In  another,  on 
the  ninth  day,  the  umbilicus  was  dried  and  cicatrized ;  in  one  on 
the  tenth  day,  the  cutaneous  ring  rather  small,  and  slightly  pro- 
jecting. In  another,  on  the  fifteenth  day,  the  cicatrix  was  per- 
fect, while  the  umbilicus  was  large,  projecting,  and  surrounded 
by  a  red  circle.  The  fourth  or  fifth  day,  then,  appears  to  be  the 
time  at  which  the  detachment  of  the  cord  is  ordinarily  effected, 
although  it  may  occur  equally  before  or  after  this  time.  It  usu- 
ally shrinks  on  the  first  day,  and  the  desiccation  immediately 
succeeds.  This  desiccation  is  complete  towards  the  third  day, 
and  it  is  on  the  fourth  or  fifth  day  that  the  cord  is  separated  from 
the  abdomen.  In  giving  these  general  rules,  I  wish  it  to  be  par- 
ticularly understood  that  they  are  subject  to  many  exceptions,  as 
we  shall  presently  see  ;  and  it  appears  to  us  very  difficult  to  in- 
dicate from  these  data,  the  precise  age  of  the  infant.  Not  much 
importance,  therefore,  should  be  attached  to  it  in  a  legal  point  of 
view. 

We  agree  perfectly  as  to  these  various  periods  with  the  authors 
who  have  written  upon  the  subject  about  which  we  are  now 
treating ;  but  particularly  with  M.  Gardien,  for  according  to 
him  the  umbilical  cord  usually  separates  from  the  fourth  to  the 
fifth  day.  Professor  Orfila  says,  in  his  "  Logons  de  Medecine  Le- 
gale,^^  that  the  umbilical  cord  begins  to  dry  away  on  the  first 
day,  and  that  it  is  usually  separated  on  the  fourth,  fifth,  or  sixth 


ON  THE  DISE.\SES  OF  INFANTS.  23 

day.  M.  Denis  also  says  that  it  dries  about  the  fourth  day,  and 
that  its  separation  is  effected  on  the  fifth,  sixth,  seventh,  or  eighth 
day.*  These  resuUs  are,  as  we  see,  very  varying,  particularly  if 
the  numerous  exceptions  already  given  are  borne  in  mind. 

It  is  nevertheless  in  our  power  to  draw  some  inferences  from 
these  data,  if  we  recollect  the  causes  which  produce  the  varia- 
tions, and  that  they  are  not  the  effect  of  chance,  as  I  shall  endea- 
vor to  show  in  considering  attentively  the  phenomena  attending 
the  separation  of  the  cord. 

In  the  first  place,  let  us  notice  that  the  attachment  of  the  cord 
to  the  abdomen,  is  exhibited  in  two  different  ways  ;  it  is  either 
broad  at  the  base,  and  the  cutaneous  ring  with  which  it  is  sur- 
rounded well  defined,  often  shooting  forth  to  the  distance  of  four 
to  six  lines  up  the  cord,  or  else  it  is  slender,  with  the  cutaneous 
ring  but  little  projecting,  already  wrinkled  into  folds,  and  presenting 
in  some  degree  the  appearance  which  it  will  have  when  the  cica- 
trix at  the  umbilicus  is  formed.  In  the  former  case  a  suppura- 
tion, more  or  less  abundant,  occurs  at  the  base,  and  the  cutaneous 
ring,  often  becoming  inflamed,  exhibits  a  red  circle,  which  fre- 
quently remains  for  a  considerable  time.  In  the  latter,  the  cord 
generally  dries  away  without  any  suppuration,  and  the  inflam- 
matory circle  is  not  very  evident,  the  desiccation  alone  producing 
the  separation.  This  is  effected  in  the  manner  pointed  out  above, 
and  is  more  particularly  evident  in  the  dog,  where  the  umbilical 
cord  dries  and  falls  at  a  very  early  period.  But  before  going 
farther,  the  following  facts  will  suflice  to  establish  the  distinction 
indicated.  Of  the  86  infants  to  whom  reference  has  been  made, 
one,  at  the  age  of  one  day,  exhibited  the  cord  fresh,  with  the  um- 
bilicus projecting,  red,  and  tumefied,  but  without  any  appearance 
of  suppuration.  I  also  observed  the  redness  of  the  umbilicus 
with  tumefaction  without  suppuration,  in  seventeen  infants.  In 
three,  aged  one  day,  the  cord  was  dried  the  half  its  length  in  the 
first  two,  and  entirely  dried  in  the  third.  Six  others  had  arrived 
at  the  age  of  two  days.  In  the  first  the  cord  was  dried,  and  in 
another  partially  so ;  the  same  with  the  third  and  fourth,  in  whom 
the  cutaneous  ring  was  very  projecting.     The  cord  was  dry  in 

*  The  separation  has  sometimes  not  occurred  until  the  tenth  day,  or  even  later.— S 


24  ON   THE    DISEASES   OF    INFANTS. 

the  fifth,  large  and  moist  in  the  sixth,  and  abounding  with  blood 
at  the  base.  There  were  four  of  the  age  of  three  days  ;  one  had 
the  cord  dry,  another  a  little  shrunk,  the  third  dry  and  thin, 
and  the  cutaneous  ring  slightly  projecting,  while  the  fourth  was 
dry.  Two  were  of  the  age  of  four  days,  with  the  cord  still  hu- 
mid at  the  base,  and  two  thirds  of  its  length  quite  dry ;  one  of  five 
days,  where  the  separation  of  the  cord  was  recent,  and  the  umbi- 
licus still  humid  ;  and  one  of  fifteen  days,  in  whom  the  cord  had 
fallen  some  time  before,  the  umbilicus  cicatrized,  and  the  cuta- 
neous ring  quite  projecting  and  surrounded  by  a  red  circle. 
Such  were  the  different  states  of  the  umbihcal  cord  in  the  infants 
where  the  umbilicus  appeared  red  and  tumefied  without  suppu- 
ration. We  will  now  see  the  condition  of  the  umbilicus  in  eight 
infants,  where,  besides  redness  and  tumefaction,  a  perfect  suppu- 
ration existed.  There  was  but  one  of  the  a^e  of  one  day.  The 
cord  in  this  one  was  dry,  the  umbilicus  a  little  projecting,  and 
the  surrounding  red  circle  very  small.  Three  others  were  two 
days  old  ;  in  one  of  these  the  cord  was  dry  at  the  summit,  its  in- 
sertion large,  and  the  cutaneous  ring  very  prominent.  In  the 
third  the  cord  had  recently  fallen.  In  three  infants  three  days 
old,  there  were  two  v/here  the  cord  was  dry,  and  in  the  third,  a  lit- 
tle shrunk.  Lastly,  there  was  one  aged  five  days,  where  the  cord 
vv^as  dry  and  very  large  at  the  point  of  insertion.  There  was  but 
one  infant  of  the  age  of  three  days,  in  whom  suppuration  existed 
at  the  base  of  the  cord,  without  surrounding  redness.  Thus  out 
of  eighty-six  infants  of  different  ages,  only  twenty-six  exhibited 
traces  of  inflammation  around  the  umbilical  ring.  This  inflam- 
mation, then,  is  not  indispensable  to  the  separation  of  the  cord, — 
it  is  not  even  a  concomitant  attendant, — since  I  have  never  ob- 
served it,  notwithstanding  the  most  scrupulous  attention,  in  the 
sixty-one  infants,  completing  the  entire  number  of  those  to  whom 
I  have  particularly  directed  my  researches.  It  should  be  re- 
membered that  I  make  a  distinction  between  the  suppuration  at 
the  base  of  the  cord,  and  the  oozing  from  the  umbilicus  which 
follows  its  separation.  In  no  instance  in  these  sixty-one  cases 
did  the  cord  exhibit  any  putrefaction,  but  nothing  more  than  a 
simple  desiccation.  I  have  often  seen  the  cord  separate  in  the 
manner  above  mentioned  without  the  concurrence  of  any  inflam- 
mation.    We  should  not,  therefore,  attach  much  importance,  as 


ON   THE    DISEASES   OF    INFANTS.  25 

has  been  done  by  some  distinguished  writers  on  legal  medicine, 
to  the  absence  or  presence  of  a  red  circle  around  the  umbilicus, 
when  we  are  examining  the  dead  body  of  an  infant  to  determine 
whether  it  died  before,  during,  or  after  birth. 

This  inflammatory  redness  proceeds  from  a  cause  which  I  will 
now  endeavor  to  explain.  It  is  worthy  of  observation  that  the 
redness  and  suppuration  were  not  manifested  except  in  about  one 
fourth  of  all  the  cases  which  form  the  subjectof  these  researches, 
and  that  the  umbilical  cutaneous  ring,jn  children  exhibiting  this 
phenomenon,  appeared  very  distinct,  and  the  cord  abounding  in 
gelatine  was  attached  by  a  large  surface  to  the  abdomen.  Ought 
we  not,  therefore,  to  attribute  this  inflammation  to  the  projecting 
of  the  umbilicus,  by  which  it  is  exposed  to  the  rubbing  of  the 
clothes  and  the  friction  of  the  dried  cord  ?  and  can  we  not  find 
in  the  gelatine  of  Wharton,  or  in  the  cellular  tissue,  which  together 
surround  the  vessels  of  the  cord,  the  materials  of  the  suppuration  ? 
This  redness  is  often  partiaL  and  is  not  manifested  except  at  that 
portion  of  the  cord  which  has  suflered  compression.  At  other 
times  the  inflammation  appears  and  disappears  several  times, 
whether  the  cord  remains  attached,  or  whether  it  has  been  for  some 
time  separated ;  and  it  is  not  uncommon  to  see  it  remain  for  seve- 
ral weeks,  producing  an  erysipelatous  affection  ontheparietesof  the 
abdomen.  In  order  to  avoid  the  irritation  produced  by  the  con- 
tact of  the  indurated  cord  upon  this  part,  we  ought  carefully  to 
remove  a  portion  where  it  has  dried,  and  always  to  apply  a  com- 
press upon  the  umbilicus,  through  the  centre  of  which  a  suita- 
ble opening  has  been  made  to  allow  of  the  passage  of  the  umbili- 
cal cord. 

Since,  in  the  separation  of  the  cord,  two  phenomena  have 
been  presented,  in  the  one  case  the  umbilicus  inflaming  and  sup- 
purating abundantly,  while  in  the  other  the  separation  is  pro- 
duced by  a  simple  desiccation,  accompanied  sometimes  by  a 
slight  oozing  from  the  base,  but  without  any  real  inflammation ; 
we  will  inquire  in  which  of  the  two  the  cord  soonest  undergoes 
separation.  The  following  facts  will  answer  this  inquiry.  In 
twenty-one  infants  of  whom  I  have  before  spoken,  when  the  cord 
had  fallen  off",  there  were  only  three  with  the  red  circle  around 
the  umbilicus.  One,  aged  five  days,  exhibited  this  redness  with- 
out suppuration ;  another,  aged  three,  had  the  redness  with  sup- 


26  ON   THE    DISEASES   OF   INFANTS. 

puration ;  in  the  third,  aged  fifteen  days,  where  the  cord  had 
been  for  some  time  separated,  the  red  inflammatory  circle  existed, 
while  the  remaining  eighteen  had  not  the  least  redness.  I  have 
before  said  that  twenty-six  infants  exhibited  the  trace  of  a  severe 
inflammation  at  the  base  of  the  cord,  and  upon  the  whole  of  the 
umbilical  ring ;  now  in  almost  all  these,  although  of  diflerent 
ages,  the  cord  at  its  insertion  was  perfectly  solid,  and  not  at  all 
dried  at  the  base,  consequently  inflammation  at  the  base  of  the 
cord  is  by  no  means  a  condition  necessary  to  accelerate  the  sepa- 
ration;  on  the  contrary,  it  occurs  in  cases  where  the  separation 
is  generally  more  slow,  for  the  cords  most  abounding  in  gelatine 
are  the  most  ready  to  suppurate.  We  know  that  the  desiccation 
of  the  base  of  the  cord  is  one  of  the  conditions  necessary  to  its 
separation,  but  the  abundance  of  gelatine  retards  this  process ; 
consequently  the  cords  that  are  provided  with  the  greatest  quan- 
tity of  this  gelatinous  matter,  are  much  slower  in  separating. 
Reasoning  and  analogy  are  here  mutually  sustained,  for  I  do  not 
reason  except  from  facts.  However,  as  it  sometimes  occurs 
equally  in  a  thin  ring,  in  which  a  cord  more  or  less  slender  is 
inserted,  a  premature  separation  of  the  cord  may  possibly  occur 
even  in  cases  of  umbilical  inflammation  ;  this  circumstance  is, 
however,  rare.  This  inflammation  must  be  considered  as  purely 
accidental,  and  not  as  an  indispensable  occurrence  to  the  separa- 
tion. Yet  we  find  in  the  cases  communicated  to  Professor  Orfila, 
and  recorded  in  his  Lecons  de  Medecine  Legale^  that  in  all  the 
subjects  the  red  circle  existed.  M.  Denis,  in  the  synoptical  table 
which  he  has  given  upon  the  diflerent  phenomena  attending  the 
separation  of  the  cord,  has  been  less  exclusive,  and  according  to 
my  views,  approaches  much  nearer  the  truth.  From  the  preced- 
ing observations,  it  is  evident  that  the  separation  of  the  cord  is 
the  result  of  the  constriction  which  the  indurated  gelatine  exer- 
cises upon  the  umbilical  vessels  at  the  umbilicus,  and  also  of  the 
continual  pulling  from  this  narrowed  point  of  the  cord  so  dried 
and  fragile  ;  and  that  there  is  neither  gangrene  of  the  cord,  as 
Haller  thinks,  nor  constriction  of  the  epidermis,  as  is  asserted  by 
Gardien, — a  constriction  which  so  inert  a  pellicle  could  hardly 
exert ;  nor  yet  a  contraction  of  the  skin  with  inflammation  of  the 
umbilicus,  as  Capuron  pretends ;  neither  is  it  necessary  that  there 
should  exist  an  active  inflammation  with  suppuration,  as  has 


ON   THE    DISEASES    OF    INFANTS.  27 

been  maintained  by  others, — this  last  condition  having  no  exist- 
ence except  in  peculiar  circumstances.  Besides,  it  is  well  known 
that  inflammation  and  suppuration  of  parts  in  which  vessels  are 
often  found,  will  not  always  cause  the  rupture  of  the  latter. 
Veins  and  arteries  are  often  seen  remaining  healthy  in  the  midst 
of  large  abscesses.  Beclard  has  observed  that  arteries  in  inflamed 
parts  hardly  ever  inflame.  Dr.  Berard,  in  his  inaugural  disser- 
tation, has  given  a  remarkable  fact  in  support  of  this  opinion.  If 
this  be  so,  how  can  it  happen  that  an  active  inflammation  of  the 
umbilicus  is  necessary  to  produce  a  rupture  of  the  umbiUcal  ar- 
teries and  vein,  that  the  separation  of  the  cord  may  be  effected  ? 

§111.  Cicatrization  of  the  umbilicus. — In  order  to  understand 
properly  the  changes  which  take  place  at  the  umbilicus  after  the 
separation  of  the  cord,  we  must  not  lose  sight  of  the  two  kinds 
of  umbilical  rings  of  which  I  have  spoken ;  the  one  but  slightly 
projecting  and  already  corrugated,  is  usually  found  among  the 
cords  that  are  thin  and  small ;  the  other  very  large  and  projecting, 
covering  a  large  portion  of  the  base  of  the  cord,  occurs  where  the 
cords  are  thick  and  moist.  In  proportion  as  the  desiccation  advan- 
ces, the  circumference  of  the  umbilicus  appears  at  first  to  gather  in 
folds  ;  and  it  often  exhibits  a  double  cutaneous  ring,  one  within 
the  other.  The  cord  detaching  itself  in  a  circular  manner,  the 
umbilicgl  circle  becomes  loose,  forming  a  funnel-shaped  hollow, 
at  the  bottom  of  which  the  cord  may  still  be  held  by  one  or  two 
vessels  which  soon  separate.  In  this  hollow  will  be  found  the 
ruptured  extremities  of  the  vessels,  surrounded  by  cellular  tissue, 
and  maintained  on  a  level  with  the  aponeurotic  circle  which  the 
linea  alba  forms  at  this  point  by  a  continuation  of  the  fascia  trans- 
versalis.  All  these  parts  sink  gradually  towards  the  cavity  of  the 
abdomen,  the  cause  of  which  may  be  seen  in  the  following  ex- 
planation. The  umbilical  arteries  and  vein  have,  until  the  pe- 
riod of  birth,  partaken  of  the  general  growth  of  the  body,  but  from 
that  moment  they  become  inactive,  receiving  no  more  blood,  the 
diameter  and  length  at  the  same  time  evidently  beginning  to  les- 
sen. The  rapid  growth  of  the  infant  during  the  first  days  of  its 
existence,  the  increasing  development  of  the  parietes  of  the  ab- 
domen continually  enlarge  the  space  between  the  umbilicus  and 
the  termination  of  the  umbilical  vessels,  the  latter  not  undergoing 
development  in  a  corresponding  manner,  they  draw,  as  we  may 


28  ON  THE  DISEASES  OF  INFANTS. 

say,  towards  themselves  the  umbilical  ring,  which,  although  pro- 
jecting and  conical  at  first,  soon  presents  a  depressed  and  funnel- 
shaped  surface.  This  force  is  counterbalanced  by  the  aponeuro- 
tic ring  of  the  linea  alba  ;  there  is  then  formed,  according  to  M. 
Denis,  a  kind  of  sac,  at  the  bottom  of  which  appears  a  species  of 
suppuration,  not  to  be  confounded  however  with  that  resulting 
from  tlie  disorganization  of  the  base  of  the  cord  in  certain  cases. 
The  cord  at  its  insertion  is  often  perfectly  dry,  whilst  the  funnel- 
shaped  hollow  of  the  umbilicus  forms  the  suppuration  to  which 
we  have  just  alluded.  It  is  entirely  different  in  composition  from 
ordinary  pus,  the  result  of  inflammation  :  at  first  the  skin  about  the 
umbilicus,  alv/ays  a  little  excoriated  at  the  pl-ace  of  separation, 
becomes  a  kind  of  mucous  membrane  secreting  a  puriform  fluid, 
and  the  cellular  tissue  at  the  same  time  itself  secreting  pus.  In 
the  centre  of  the  umbilicus  is  seen  a  soft  tubercle  more  or  less  red, 
formed  by  the  extremities  of  the  vessels  re-united,  which  disap- 
pearing by  degrees,  is  at  last  imbedded  in  the  abdomen.  KSome- 
times  this  tubercle  inflames,  becomes  fimgous,  and  forms  in  the 
centre  of  the  cutaneous  ring  an  excrescence  requiring  cauteriza- 
tion. The  umbilical  vessels  form  at  their  point  of  union  an  an- 
gle which  opens  in  proportion  to  the  retraction  of  the  umbilicus, 
and  when  the  hollow  is  deep,  the  skin,  gathering  in  a  circular  man- 
ner, unites  with  much  more  facility  as  its  borders  are  a  little  ex- 
coriated, and  an  adhesive  inflammation  is  here  formed.  At  this 
time  the  skin  exhibits  a  cicatrix  crossed  by  several  small  white 
lines  at  the  point  of  its  union ;  continuing  without  alteration  dur- 
ing life.  The  skin  appears  to  be  drawn  to  the  bottom  of  the  um- 
bilicus by  means  of  the  cellular  adhesions  which  unite  it  at  the 
lower  part  of  the  sac  with  the  umbilical  vessels,  and  these  adhe- 
sions becoming  closer  and  more  solid  at  the  internal  surface  of  the 
cutaneous  fold,  it  is  thus  constricted  in  all  its  circumference  by 
the  aponeurotic  circle  of  the  linea  alba. 

When  the  cicatrization  at  the  bottom  of  the  umbilicus  is  com- 
pleted, the  umbilical  ring  assumes  internally  a  new  form,  it  is  no 
longer  circular,  but  has  two  edges, — the  one  superior,  often  very 
thick ;  the  other  inferior,  and  almost  always  thin.  It  becomes 
crescentic  in  its  shape,  the  convexity  of  one  border  corresponding 
with  the  concavity  of  the  other ;  by  which  a  semi-circular  hol- 
low is  formed  in  the  centre  of  the  umbilicus,  the  concavity  of 


ON  THE  DISEASES  OP    INFANTS.  29 

which  has  sometimes  a  superior  and  sometimes  an  inferior  aspect ; 
more  frequently  however  the  latter,  as  the  drawing  of  the  umbili- 
cal arteries  is  much  greater  than  that  of  the  vein.  The  pro- 
gressive growth  of  the  abdomen,  its  fat  or  lean  condition,  etc., 
often  modify  the  shape ;  but  such  is  the  original  form  of  the 
umbilicus  in  most  cases.  When  it  is  so  found  in  the  dead  body, 
and  should  there  also  be  at  the  umbilicus  a  puriform  oozing, 
we  may  infer  that  the  separation  of  the  cord  had  been  recent. 
M.  Denis  has  described  two  circles  ;  one,  which  surrounds  the 
cord  before  its  separation,  by  the  name  of  the  temporary  cutane- 
ous ring,  and  that  which  remains  during  life  by  the  appellation 
of  permanent  ring.  This  distinction  is  quite  proper,  but  he  has 
erred  in  calling  the  form  circular ;  it  is  such  as  I  have  above  de- 
scribed. The  two  opposing  edges  are  evidently  the  effects  of  the 
umbilical  arteries  and  vein  in  opposite  directions.  This  drawing 
is  ordinarily  greater  at  the  lower  than  at  the  upper  border,  and 
the  superior  edge  is  almost  always  observed  to  cover  the  inferior. 

From  the  10th  or  12th  day  the  cicatrization  is  complete,  and 
the  oozing  from  the  umbilicus  ceases  ;  this,  however,  varies  con- 
siderably. The  cicatrix  is  sometimes  closed  sooner,  and  the  form 
of  the  umbilicus  is  one  of  the  causes  of  the  length  of  time  re- 
quired for  its  accomplishment.  If  the  ring  be  thin  and  the  cord 
small,  it  i^  very  soon  effected.  If,  on  the  contrary,  the  ring  be  vo- 
luminous\.nd  extend  very  much  up  the  cord,  the  retraction  and 
cicatrization  are  much  more  slow  in  their  progress.  Thus,  when 
a  cicatrized  umbilicus  is  observed  in  an  infant,  we  should  bear  in 
mind  these  differences  in  the  umbilical  ring.  In  general,  when 
the  ring  is  thin  and  the  cord  slender,  the  desiccation  and  separa- 
tion of  the  cord  and  the  cicatrization  of  the  umbilicus  will  ter- 
minate before  the  10th  day.  If  we  meet  with  a  very  projecting 
umbilicus,  as  it  corresponds  probably  with  a  thick  cord,  we  may 
conclude  that  the  cicatrization  was  not  completed  until  after  the 
10th  day. 

Avariety  of  pathological  causes,  such  as  inflammation,  hernia,  or 
certain  monstrosities,  may  retard  the  progress  of  the  cicatrization, 
or  cause  it  to  be  varied  in  form.  Each  of  these  diseases  will  be 
considered  in  their  proper  place  in  the  course  of  this  work.  1 
will  not  therefore  stop  to  describe  them  here.  Upon  examining 
the  centre  of  the  umbilicus  with  attention,  a  sort  of  hardened 


30  ON   THE    DISEASES    OP    INFANTS. 

tubercle  will  be  seen,  produced  by  the  obliterated  extremities  of 
the  arteries  and  vein  united.  As  the  infant  advances  in  age,  this 
space  becomes  narrower,  the  tubercle  and  the  umbilical  centre 
sink  inward,  the  edges  of  the  cutaneous  ring  approach,  and  be- 
come almost  in  contact,  while  a  true  cicatrix  forms,  and  solidifies 
on  a  level  with  the  vascular  tubercle,  which  retracts  more  and 
more  in  drawing  to  it  the  irregular  centre  of  the  umbilical  cica- 
trix.* 


CHAPTERIV. 

ON   THE    EXFOLIATION    OP   THE    EPIDERMIS. 

Another  phenomenon  not  less  interesting  than  that  we  have 
just  been  considering,  is  the  separation  of  the  epidermis,  which 
takes  place  at  an  indeterminate  period  from  birth. 

This  exfoliation  of  the  epidermis  will  be  examined,  1st.  In  re- 
ference to  the  period  of  its  occurrence,  2dly.  The  manner  of  its 
operation,  and  3dly.  The  physiological  and  practical  inferences 
which  may  be  drawn  from  it. 

The  epidermic  exfoliation  does  not  occur  until  after  birth.  I 
know  of  no  case  where  it  has  ever  commenced  before,  and  it  is 
worthy  of  remark,  that  premature  children  have  never  exhibited 
this  phenomenon  ;  some  time  must  elapse,  and  the  infant  arrive 
at  a  certain  age,  before  it  occurs.  Authors  on  legal  medicine 
have  endeavored  to  draw  certain  inferences  from  the  separa- 
tion of  the  epidermis,  in  relation  to  the  age  of  the  infant ;  and 
M.  Orfila  being  desirous  of  examining  closely  the  statements 
of  Chaussier,  M.  Capuron,  etc.,  upon  this  subject,  has,  in  connex- 
ion with  M.  Thierry,  made  considerable  researches,  from  which 
he  has  concluded  that  the  epidermic  exfoliation  exhibits  at  first  a 
preparatory  stage,  next  an  elevation  of  the  epidermis,  and  lastly, 
its  separation.  According  to  him,  the  preparatory  stage  can  be 
observed  from  the  sixth  to  the  eleventh  day  ;  the  elevation  of  the 
epidermis  on  all  parts  of  the  body,  from  the  twentieth  to  the  thir- 

See  Appendix,  page  547. 


ON   THE    DISEASES    OP    INFANTS.  31 

tieth  day,  and  the  complete  exfoliation  from  the  thirty-fifth  to  the 
fortieth  day.  These  authors  also  state,  that  certain  diseases  re- 
tard or  suspend  this  process.  Before  offering  my  own  opinion 
upon  the  subject,  I  will  exhibit  the  facts  I  have  gathered,  and  the 
natural  inferences  flowing  from  them. 

The  eighty-six  infants  among  whom  my  researches  were  made, 
in  relation  to  the  umbilical  cord,  have  equally  served  my  purpose 
in  clearing  up  the  point  now  under  consideration. 

The  exfoliation  had  not  commenced  in  forty-two  ;  fourteen  of 
them  were  of  the  age  of  one  day,  eleven  of  two  days,  nine  of 
three  days,  five  of  four  days,  two  of  five  days,  one  of  nine  days, 
and  one  of  ten  days.  From  this  it  appears,  that  the  commence- 
ment of  the  process  is  extremely  variable  ;  however,  it  must  be 
observed;  that  far  the  greater  number  where  it  did  not  exist, 
were  of  the  age  of  one  or  two  days,  consequently  it  does  not 
occur  immediately  after  birth.  We  will  now  see  what  were  the 
ages  at  which  the  phenomenon  occurred  ;  but  before  examining 
the  subject  any  farther,  let  us  consider  the  manner  in  which  it 
is  effected. 

I  have  not  been  able  clearly  to  observe  the  preparatory  stage 
of  which  Orfila  and  Thierry  speak.  The  latter  is  not  sufficient- 
ly explicit  as  to  what  he  means  by  it ;  I  believe  that  as  soon  as 
the  skii^  breaks,  a  true  elevation  of  the  cuticle  takes  place. 
There  can  be  but  two  well-defined  periods  in  the  epidermic  exfoha- 
tion, — the  raising  of  the  cuticle,  and  its  separation.  The  eleva- 
tion occurs  in  three  different  modes  ;  in  lines  or  ridges,  in  large 
plates,  or  in  furfuraceous  scales  ;  this  has  been  noted  by  Orfila. 
These  varieties  depend  on  the  part  of  the  body  affected ;  thus 
the  lines  or  ridges  occur  in  the  flexures  of  the  joints,  in  the 
groins,  in  the  folds  of  the  arms,  etc.  The  broad  plates  are  form- 
ed between  these  folds  upon  the  chest,  often  at  the  bottom  of  the 
foot,  and  sometimes  upon  the  abdomen.  The  furfuraceous  scales 
are  seen  about  the  sternum,  under  the  armpits,  on  the  cheeks, 
between  the  shoulder  blades,  upon  the  shoulders,  back,  etc.  I 
have  noticed  with  great  care  these  different  modes  of  exfoliation, 
and  have  also  paid  close  attention  to  the  age  at  which  it  most 
commonly  begins,  and  the  manner  of  its  occurrence. 

Among  the  number  above  mentioned,  there  were  forty-four 
exhibiting  the  exfoliation;  but  to  present  the  various  phenomena 


32  ON   THE    DISEASES   OP    INFANTS. 

in  their  proper  order,  I  shall  divide  these  cases  into  three  classes. 
Where  the  exfoliation  had  commenced,  where  it  was  in  a 
state  of  full  activity,  and  lastly,  where  it  had  terminated. 
The  epidermis  was  observed  to  commence  its  elevation  in 
eleven  children  in  various  parts  of  the  body,  either  by  lines,  ei 
furfuraceous  scales,  but  it  was  easily  to  be  seen  that  it  had  com- 
menced its  detachment  from  the  skin ;  for  in  pinching  or  rub- 
bing the  skin,  it  appeared  to  move  under  the  fingers  ;  it  was  also 
remarkable  for  its  dryness,  and  its  appearance  contrasted  strongly 
with  the  other  parts  of  the  body  where  the  skin  was  smooth,  and 
the  epidermis  united  and  perfectly  adherent  to  it.  This  condition 
was  apparent  more  particularly  at  the  abdomen,  the  slightly 
roughened  appearance  of  which,  had  a  great  resemblance  to  the 
pellicles  which  form  on  the  surface  of  milk,  when  at  the  point 
of  ebullition.  On  the  next  and  the  following  days,  the  lines 
and  the  numerous  scales  were  developed  on  the  surface,  and  the 
separation  of  the  epidermis  followed  as  in  other  infants.  It  is, 
perhaps,  this  peculiar  condition  of  the  epidermis  which  has  been 
denominated  by  Thierry,  the  preparatory  stage ;  however  this 
may  be,  it  is  not  an  indispensable  occurrence  to  its  detachment, 
for  it  is  very  rarely  met  with,  since  the  exfoliating  lines  often 
form  without  any  preliminary  symptoms.  Of  the  three  children 
of  whom  I  have  just  spoken,  one  was  aged  three  days,  another 
one  day,  the  third  two  days.  There  were  only  eight  children 
who  presented  some  faintly  formed  lines  on  the  abdomen,  or  on 
the  base  of  the  chest ;  three  of  these  were  aged  one  day,  three 
two  days,  one  three  days,  and  one  four  days.  In  the  three  aged 
two  days,  small  scales  were  seen  in  the  axilla,  and  lines  in  the 
folds  of  the  neck  and  groin.  I  believe  that  the  exfoliation  of  the 
epidermis  may  be  considered  as  having  commenced  in  all  these 
children,  but  their  ages  varied  so  much,  that  it  is  impossible 
to  say  precisely  at  what  period  it  usually  commences. 

The  exfoliation  was  at  its  height,  that  is  to  say,  extensive 
scales,  or  extensive  zones  of  the  epidermis,  were  raised  at  differ- 
ent points  of  the  surface  of  the  body,  in  thirty-two  children  ;  only 
one  was  of  the  age  of  one  day,  seven  were  of  two  days,  eight  of 
three  days,  six  of  four  days,  six  of  five  days,  one  of  seven  days, 
two  of  nine  days,  and  one  of  fifteen  days. 

From  three  to  five  days,  then,  appears  to  be  the  age  at  which 


ON  THE    DISEASES    OF    INFANTS.  33 

the  epidermic  exfoliation  is  at  its  greatest  height.  I  have  already- 
said  that  it  was  not  observed  in  forty-two  children  ;  I  will  add, 
that  there  are  instances  where  it  occurs,  as  we  may  say,  insensi- 
bly, for  none  of  these  children  presented  the  exfoliated  lines  or 
plates,  as  we  have  just  described  them.  The  epidermis,  in  such 
a  case,  comes  off  in  a  dust ;  and  the  different  periods  of  exfoliation 
cannot  be  observed.  This  ought  therefore  to  be  denominated 
the  insensible  exfoliation  of  the  epidermis.  Being  unable  to 
assign  any  cause  for  this  difference,  1  have  limited  myself  to  the 
simple  mention  of  the  fact. 

The  duration  of  this  process  is  very  variable.  It  has  continu- 
ed until  the  thirtieth  or  fortieth  day,  and  even  for  two  months. 
Often  its  duration  is  much  longer,  and  it  is  very  strongly  mark- 
ed in  those  children  v/ho  have  become  affected  with  marasmus, 
the  fiaccidity  of  the  integuments  allowing  the  epidermis  to  be- 
come detached  in  large  scales.  It  is  doubtless  from  this  fact 
that  M.  Thierry  has  given  it  as  his  opinion,  that  gastro  enterites 
retards  the  exfoliation.  We  must  not,  however,  confound  the  re- 
tarding of  the  process  with  its  prolongation ;  let  us  rather  at- 
tribute the  promoting  of  it  to  the  state  of  dryness  and  fiaccidity 
of  the  integuments,  to  which  condition  they  are  reduced  by  ma- 
rasmus. There  exists  in  adults  an  analogous  phenomenon, 
where  disease  has  produced  a  rapid  emaciation.  In  the  course  of 
their  convalescence,  according  to  the  popular  phrase,  they  change 
their  skin.  It  appears  as  if  nutrition  had  been  entirely  suspend- 
ed in  those  parts  in  which  it  naturally  proceeded  in  a  feeble  man- 
ner, and  that  the  epidermis  being  thus  deprived  of  its  portion  of 
blood,  had  become  withered  and  dead.  The  effect,  therefore,  of 
marasmus  in  children,  is  to  prolong  the  separation  of  the  cutis. 

The  cause  of  the  epidermic  exfoliation  in  new-born  children, 
is  susceptible  of  a  satisfactory  explanation.  The  integuments 
of  the  infant  are  for  about  seven  months  immersed  in  a  liquid 
which  keeps  them  constantly  supple  and  moist.  The  epidermis, 
until  the  period  of  birth,  is,  as  it  were,  soaking  in  the  waters  of 
the  amnios.  When  exposed  to  the  air,  it  becomes  suddenly  dried, 
and  loses  the  suppleness  peculiar  to  it  during  the  intra-uterine 
existence.  Hence  results  a  cracking  and  scaling  of  the  epidermis, 
and  its  final  separation  in  the  form  of  plates  or  powder. 

In  proportion  as  the  epidermic  scales  are  raised,  the  epidermis 


34  ON   THE    DISEASES    OF   INFANTS. 

forms  beneath  in  an  imperceptible  manner.  The  skin  beneath  the 
elevated  scales  is  red,  very  irritable,  and  inflames  with  great  fa- 
cility. I  have  seen  the  epidermis  on  the  scrotum  of  an  infant  en- 
tirely removed.  The  skin  of  this  part  being  in  contact  with  the 
urine,  inflames,  and  becomes  aflected  with  severe  erysipelas. 
The  epidermis  is  very  soon  reproduced  in  those  parts  which  are 
most  exposed  to  the  air,  but  the  folds  of  the  skin,  as  in  the  arm- 
pits, the  neck,  or  groin,  or  any  other  parts  deprived  of  a  direct 
contact  with  the  air,  secrete  a  fluid  like  that  formed  by  mucus 
membranes.  This  is  easily  dried  up,  in  assisting  the  formation  of 
a  new  epidermis  by  the  use  of  absorbing  powders.  This  cir- 
cumstance serves  to  prove  that  the  epidermis  is  only  a  cutaneous 
secretion ;  a  covering  almost  inorganic,  being  destroyed  and 
re-established  according  as  the  cutaneous  surfaces  are  expo- 
sed to  the  action  of  the  air,  or  are  kept  from  its  direct  influence. 

The  elevation  of  the  epidermis  in  young  infants  favors  very 
considerably  cutaneous  absorption,  since  the  absorbing  surface  is 
no  longer  covered ;  a  circumstance  not  to  be  overlooked  in  ther- 
apeutics, for  we  may,  by  means  of  the  skin,  introduce  substances 
into  the  system,  often  difiicult  to  administer  in  the  usual  manner. 
Endermic  medication  may  very  often  be  used  with  advantage. 

Care  must  be  taken  not  to  confound  the  natural  exfoliation  of 
the  epidermis  with  the  separation  which  occurs  from  putrefaction ; 
in  the  latter  case,  the  surface  of  the  abdomen  is  usually  green  ; 
universal  evidences  of  putrefaction  exist,  and  when  the  epider- 
mis is  carefully  raised,  a  number  of  very  fine  colorless  filaments 
are  to  be  seen,  which  break  after  being  somewhat  stretched.  I 
have  observed  that  these  are  not  to  be  seen  in  the  natural  sepa- 
rations of  the  epidermis.  Several  anatomists,  such  as  William 
Hunter,  Bichat,  and  Chaussier,  have  regarded  them  as  vessels, 
but  as  they  are  not  observed  except  in  a  state  of  putrefaction, 
ought  they  not  to  be  considered,  as  Beclard  judiciously  observes, 
as  the  rete  mucosum  rendered  fluid  and  viscous  by  the  com- 
mencement of  the  process  of  decomposition  ? 

I  have  sometimes  seen  the  exfoliation  occur  twice  in  the  same 
child.  It  is  not  unusual  to  see  children  during  the  month,  exni- 
bit  the  natural  process  of  epidermic  exfoliation.  If  at  the  end  of 
this  period  they  should  become  emaciated  by  disease,  the  epider- 
mis on  the  abdomen  or  limbs  is  again  detached  ;  it  then  raises  in 


ON   THE    DISEASES    OP    INFANTS.  35 

very  large  plates,  or  in  large  zones  on  the  abdomen,  and  furfura- 
ceous  scales  exhibit  themselves  in  abundance  on  various  other 
parts  of  the  body.  The  hands  and  feet  exhibit  then,  more  often 
than  in  the  first  instance  the  epidermic  exfoliation,  attributable  in 
reality  to  the  emaciation  caused  by  the  chronic  disease  under 
which  the  child  has  labored.  If  M.  Thierry  has  observed  this 
secondary  exfoliation  in  children  a  little  advanced  in  age,  he  has 
thought  that  the  gastro  enterites  with  which  they  were  affected, 
had  retarded  its  development,  while  on  the  contrary  it  was  the 
cause  of  its  existence.  In  this  manner  can  the  assertion  on  this 
subject  in  Orfila's  work  be  explained. 

It  is  difficult  to  establish  any  constant  conformity  between  the 
separation  of  the  epidermis  or  that  of  the  cord,  and  the  age  of 
an  infant ;  and  even  the  attempt  to  draw  any  general  consequen- 
ces from  these  two  phenomena  have  been  in  vain.  The  result, 
however,  of  these  considerations,  is,  that  the  epidermic  exfolia- 
tion of  young  infants  is  a  natural  phenomenon,  and  is  decidedly 
one  of  health. 


CHAPTER  V. 

OF   THE   SIZE    AND    WEIGHT   OP   THE    INFANT. 

From  the  time  of  birth  to  the  seventh  month  the  infant  grows 
rapidly,  assimilation  proceeds  with  great  activity,  and  it  acquires 
a  considerable  size  compared  with  what  it  had  at  the  time  of 
birth  ;  the  limbs  also  enlarge  in  a  very  remarkable  manner. 

Professor  Chaussier  has  remarked,  that  the  embryo  increases 
at  the  rate  of  two  inches  a  month ;  whence  it  must  follow  that  at 
the  period  of  birth  it  will  be  about  eighteen  inches  in  length. 
This,  therefore,  ought  to  be  the  size  of  an  infant  when  first  born, 
according  to  the  calculation  of  this  celebrated  anatomist.* 

I  have  measured  a  number  of  infants  from  the  age  of  one  day 
to  that  of  a  month,  in  order  to  have  a  precise  knowledge  of  the 

*   Table  synoptique  dcs  mesures  relatives  a  V etude  et  a  la  -pratique  des  accouchmens. 


36  ON   THE    DISEASES    OF    INFANTS. 

size  of  newly  born  children,  without  regarding  the  growth  of  the 
embryo.  The  following  are  the  general  results  of  these  re- 
searches : — 

I  took  by  chance,  and  without  distinction  of  sex  or  age,  fifty- 
four  children,  in  order  to  ascertain  the  mean  size.  Of  these 
there  were  seven  of  the  age  of  one  day,  born  at  the  full  time ; 
one  measured  sixteen  inches,  two  seventeen  inches,  two  fifteen 
inches  six  lines,  one  nineteen  inches,  and  the  other  eighteen  inches. 
Of  three  children,  apparently  born  before  the  full  time,  and  aged 
one  day,  one  was  twelve  inches  in  length,  another  fourteen  and 
a  half,  and  the  third  fifteen.  There  were  three  aged  two  days ; 
one  was  seventeen  inches,  (female  ;)  another  the  same ;  and  the 
third  nineteen,  (male.)  There  were  six  aged  three  days,  (males,) 
feeble  and  apparently  born  prematurely ;  the  first  three  were 
each  fifteen  inches  six  lines  ;  the  fourth  fourteen  inches  three 
lines ;  the  fifth  (female)  was  seventeen  inches  ;  the  next  (male) 
nineteen  ;  one  of  four  days,  (male  full  grown,)  was  sixteen  inches 
four  lines  ;  three,  aged  five  days,  were — one  fifteen  inches  six  lines, 
(female,)  another  seventeen  inches,  (female,)  and  the  third  seven- 
teen inches  two  lines ;  three  were  aged  six  days,  one  (male)  was 
seventeen  inches,  another  (female)  seventeen  inches  one  line, 
and  the  third  (female)  sixteen  inches.  In  four  infants  aged 
seven  days,  there  was  one  (male)  seventeen  inches  five  lines ; 
another  (male)  seventeen  inches  six  lines  ;  another  (female)  fifteen 
inches  ten  lines ;  another  (male)  seventeen  inches ;  three  were 
aged  eight  days,  one  (female)  seventeen  inches  six  lines,  another 
(female)  seventeen  inches  nine  lines,  the  third  (male)  seventeen 
inches;  of  two  aged  nine  days,  one  measured  nineteen  inches  eight 
lines,  the  other  one  (a  female)  seventeen  inches  six  lines ; 
one  of  twelve  days,  (male,)  nineteen  and  a  half  inches  ;  three  of 
fourteen  days,  (two  of  these  females,)  were  seventeen  inches,  and 
the  third  (male)  sixteen  inches  six  lines;  one  aged  seventeen 
days,  (female,)  seventeen  inches  six  lines ;  three  of  eighteen 
days,  the  first  (male)  seventeen  inches  three  lines,  the  second 
(female)  eighteen  inches  six  lines,  the  third  (male)  eighteen 
inches  ;  one  aged  twenty  days,  (female,)  eighteen  inches  six  lines ; 
one  aged  twenty-one  days,  (male,)  nineteen  inches  ;  five  aged 
one  month,  the  first  of  these  (female)  measured  sixteen  inches 
six  lines,  the  second  (male)  seventeen  inches  eight  lines,  the  third 


ON    THE    DISEASES    OP    INFANTS.  37 

(male)  nineteen  inches,  the  fourth  (male)  sixteen  inches  six  lines, 
the  fifth  (female)  seventeen  inches  four  lines. 

From  this  exhibition  it  will  be  seen  that  the  size  of  the  chil- 
dren measured  did  not  exceed  eighteen  inches,  and  that  the 
greatest  number  were  about  seventeen  inches  ;  since,  in  the  fifty- 
four  of  whom  we  have  been  speaking,  there  were  twenty-two 
measuring  seventeen  inches,  and  only  four  measuring  eighteen  ; 
the  remainder  nineteen,  sixteen,  or  fifteen  inches.  From  six- 
teen to  seventeen  inches,  then,  appears  to  be  the  ordinary  size  of 
newly  born  infants.* 

The  facts  show  that  it  is  impossible  to  assign  any  size  as 
common  to  all  young  infants ;  they  differ  in  this  respect  almost 
as  much  as  adults.  Some  are  born  with  a  high  degree  of  vigor, 
and  appear  large  and  strong  ;  while  others,  small  and  debilitated, 
bear  the  impress  of  a  feeble  constitution,  which  they  carry  with 
them  through  life.  All  the  varieties  of  size,  strength,  shape, 
and  color  exhibited  in  the  human  species,  are  evident  in  the 
cradle. 

Professor  Chaussier,  in  the  synoptical  table  of  which  mention 
has  already  been  made,  after  having  designated  eighteen  inches 
as  the  usual  size  of  a  child  born  at  nine  months,  has  thought 
proper  to  qualify  his  general  assertion,  and  adds  : — "  Sometimes 
we  see  a  foetus  born  at  the  full  time  not  more  than  fourteen  or 
fifteen  inches  in  length  ;  at  other  times  they  have  been  seen 
measuring  twenty-seven  inches,  an  instance  of  which  has  been 
reported  by  Millet." 

It  is  difficult  to  establish  exactly  the  growth  of  a  child  in  each 
month,  from  birth  to  the  age  of  seven  or  eight  months.  Children 
exhibit  in  this  respect  difference  according  to  their  constitution, 
and  the  diseases  which  affect  them  at  this  period  of  their  life.  I 
have  not  sufficient  data  upon  the  subject  to  allow  of  its  consider- 
ation in  this  place. 

As  to  the  weight  of  a  new-born  child,  it  deserves  but  a  second- 
ary consideration.  It  has  been  exactly  established  by  very  close 
observers,!  who  agree  in  stating,  that  at  nine  months  an  infant 
weighs  from  five  to  five  pounds  and  a  half  Chaussier  says 
that  children  are  sometimes  found,  born  at  the  full  time  and 
quite  active,  weighing  but  one  thousand  three  hundred  grammes, 

*  See  Appendix,  page  548.  t  Chaussier,  Baudelocque,  &c 


38  ON   THE    DISEASES    OP    INFANTS. 

(about  two  pounds  and  a  half;)  others,  one  thousand  seven  hun- 
dred and  fourteen  grammes,  (a  httle  more  than  three  pounds  and 
a  half.)  Generally  their  weight  is  between  six  and  seven 
pounds  ;  they  are  rarely  seen  weighing  four  thousand  four  hun- 
dred grammes,  (about  nine  pounds;)  they  have  been  seen,  but 
very  rarely,  weighing  six  thousand  eight  hundred  grammes, 
(about  twelve  pounds.)  Baudelocque  saw  one  which  weighed 
five  thousand  three  hundred  grammes,  (or  about  eleven  pounds  ;) 
but  how  can  we  believe,  as  has  been  asserted  by  some,  that  thera 
have  been  infants  weighing  more  than  twenty-three  or  twenty 
five  pounds  ? 


CHAPTER   VI. 

OP     THE     MEANS    OP     EXPRESSION     IN    THE     INPANT. THESE 

ARE    LIMITED    TO    THE    CRY   AND    EXPRESSION   OP    FACE. 

Article  I. 

OF   THE    CRY    CONSIDERED    IN    RELATION    TO    SEMEIOLOGY. 

Section  I.  Analysis  of  the  cry. — When  we  give  but  a  slight 
attention  to  the  cry  of  a  child,  we  hear  nothing  but  a  uniform 
noise  ;  the  vagitus,  or  cry  of  a  new-born  child,  is  always  easily 
distinguished  from  the  other  noises  which  constantly  strike  the 
ear  ;  but  if  we  listen  more  attentively,  we  shall  discover  that  the 
cry  is  composed  of  two  distinct  parts,  the  one  sonorous  and  pro- 
longed, only  heard  during  expiration,  ceasing  and  commencing 
with  it,  and  caused  by  the  air  passing  from  the  lungs  through 
the  glottis.  This  is  the  proper  cry.  The  other  partis  produced 
by  inspiration ;  the  air  in  passing  through  the  glottis,  in  order  to 
reach  the  lungs,  is  compressed  by  a  kind  of  spasmodic  contrac- 
tion of  the  vocal  muscles,  giving  a  shorter,  more  acute  sound 
than  the  proper  cry,  and  often  less  perceptible ;  it  is  an  interval, 
a  sort  of  effort  at  renewal  between  the  cry  just  finished  and  that 


ON   THE    DISEASES    OF    INFANTS.  39 

about  being  commenced.  Often  the  cry  exists  alone,  and  the 
sound  of  the  interval  or  reprise  is  not  heard  at  all ;  or  the  reprise 
is  heard,  while  the  cry  is  stifled.  The  cry  and  the  reprjse  often 
have  very  important  modifications  with  which  it  is  necessary 
to  be  acquainted,  and  which  we  will  hereafter  point  out. 

The  younger  the  infant,  the  less  is  the  reprise  heard ;  it  very 
sensibly  increases  as  the  child  advances  in  age  ;  the  sound  varies 
from  the  whistling  of  the  blowing  of  wind  to  that  of  the  shrill 
voice  of  a  young  cock.  It  appears  to  augment  in  intensity  in 
an  inverse  ratio  to  that  of  the  cry.  When  the  child,  after  having 
cried  a  great  deal,  becomes  exhausted  by  fatigue,  want  of  sleep, 
or  pain,  the  reprise  then  predominates  ;  this  is  the  sound  which 
is  heard  from  time  to  time  in  the  sobs  of  a  child,  finally  termi- 
nating in  profound  sighs  elicted  by  the  recollection  of  recent  pain. 

The  peculiar  tone  of  the  cry  varies  as  much  as  the  voice  in 
adults  ;  it  exhibits  in  each  infant  particular  modifications  which 
it  is  difficult  to  describe,  but  which  are  easily  discerned  by  the  ear. 
The  heart  of  a  mother  responds  not  to  the  cries  of  strange  chil- 
dren, but  her  own  cherished  one  is  immediately  recognized 
among  all  others. 

From  what  we  have  seen,  the  cry  is  really  nothing  more  than 
a  sonorous  inspiration  and  expiration.  The  infant  might  there- 
fore be  expected  to  exhibit,  while  crying,  the  effect  of  painful  and 
forced  respiration  in  the  muscles  of  the  face  and  trunk.  Mr. 
Charles  Bell  has  demonstrated  by  his  experiments,  thtit  the  portio 
dura  of  the  seventh  pair  of  nerves  is  the  respiratory  nerve  of 
the  face  ;  that  is  to  say,  its  office  is  to  transmit  the  power  of  mo- 
bility to  those  muscles  controlling  the  various  openings  through 
which  the  air  passes  to  the  kings.  Now,  during  the  crying  of  a 
child,  the  motions  of  all  the  parts  concerned  in  respiration  be- 
come, as  we  may  say,  convulsive,  and  whilst  the  diaphragm 
and  thoracic  muscles  are  contracted  with  considerable  force,  those 
of  the  face  at  the  same  time  act  with  great  power,  and  give  to  it 
a  peculiar  expression.  It  is  well  known  that  these  motions 
among  the  muscles  of  the  trunk  and  face,  are  owing  to  the 
anastomosing  of  the  branches  of  nerves  of  these  parts.  When 
we  examine  a  child  about  commencing  to  cry,  we  shall  see  that 
the  face  reddens,  the  inspiratory  motions  become  strong,  the 
mouth  opens,  exhibiting  the  borders  of  the  gums ;  the  tongue  is 


40  ON   THE    DISEASES    OF    INFANTS. 

sometimes  agitated  by  a  slight  convulsive  movement,  the  nostrils 
dilate,  the  eyes  close,  the  eyelids  swell,  three  or  four  vertical  lines 
appear  at  the  root  of  the  nose,  others  also  on  the  forehead ;  they 
cross  each  other  in  all  directions,  and  vary  considerably  as  to 
their  number  and  direction.  At  every  movement  of  expiration  and 
inspiration  they  alternately  appear  and  disappear.  If  the  crying 
is  prolonged,  the  infant  will  at  the  same  time  move  its  lipbs, 
following  the  elevating  and  depressing  motions,  as  if  to  assist  the 
dilating  muscles  of  the  chest.  It  sometimes  happens  at  first,  that 
these  different  muscular  contractions,  and  these  painful  efforts  at 
inspiration,  are  not  accompanied  with  any  noise  ;  they  are  soon 
succeeded  by  a  short  cry  but  little  sustained,  then  followed  by  a 
continued  cry,  terminating  finally  in  a  full  and  sonorous  sound. 
It  also  happens  that  the  reprise  is  at  first  soft,  and  cannot  be 
heard  but  for  a  moment.  Often  three  or  four  cries  will  follow 
each  other  in  quick  succession,  then  a  little  interval  will  be  heard, 
to  which  succeeds  a  cry  of  much  longer  duration  than  the  pre- 
ceding, at  last  terminating  in  a  sound  somewhat  resembling  that 
of  the  bleating  of  a  goat. 

Whilst  the  child  holds  its  breath  the  mouth  remains  open,  and 
the  face  is  in  a  state  of  permanent  contraction,  until  the  laborious 
effort  at  respiration  is  at  last  terminated  by  a  violent  cry,  appa- 
rently the  result  of  this  long  and  distressing  exertion. 

This  alternate  succession  of  crying,  of  respite,  and  of  mus- 
cular contractions  of  the  thorax  and  face,  is  observed  while  the 
agitation  of  the  child  continues ;  as  soon  as  it  becomes  more 
calm,  the  harmony  between  the  inspiration  and  expiration  is  re- 
established, and  the  cry  is  less  intense.  The  reprise  is  now 
much  more  easily  distinguished,  the  wrinkles  in  the  face  dis- 
appear, the  mouth  gradually  closes,  and  a  universal  calmness 
takes  the  place  of  the  disturbance  which  we  have  just  described. 

It  is  an  important  fact  to  notice  here,  that  very  young  children 
never  shed  tears  while  they  cry,  or  at  least,  it  is  of  very  rare 
occurrence.  The  secretion  of  the  lachrymal  gland  is  excited,  as 
is  well  known,  immediately  and  sympathetically  by  sorrow  ;  but 
are  children  at  the  tender  age  of  which  we  are  speaking,  under 
the  influence  of  mental  emotions  ?  Is  this  secretion  produced  by 
any  other  influence  than  thle  nervous  excitability  proceeding 
from  some  moral  cause  ?    And  are  physical  distresses,  which  ap- 


ON   THE    DISEASES    OF    INFANTS.  41 

pear  to  be  the  only  kind  endured  by  a  being  whose  brain  cannot 
as  yet  combine  ideas,  and  from  which  there  appears  to  emanate 
no  vohiion  capable  of  acting  on  this  gland  ?  These  are  questions 
which  it  is  difticult  to  answer.  The  lachrymal  gland  at  this  pe 
riod  is  perfectly  developed,  it  receives  arteries  and  nerves,  and 
does  not  diifer  anatomically  from  other  glands.  Notwithstanding 
this,  no  tears  flow  while  the  child  is  crying  ;  and  while  the  sim- 
ple recollection  of  a  lost  friend,  dear  to  us^  will  fill  the  eyes 
with  abundance  of  tears,  yet  in  the  ^^oung  infant,  in  spite  of  the 
reiterated  cries  from  sleeplessnesSj  sickness,  and  painj  the  lachry- 
mal secretion  remains  undisturbed ;  a  fact  deserving  the  attention 
of  physiologists.  It  is  a  remarkable  example  of  the  particular 
influence  of  the  nervous  system  on  the  functions  of  certain  or- 
gans of  the  body. 

Such  is  the  analysis  of  the  cry  of  a  new-born  child,  and  such 
is  the  exhibition  of  the  accompanying  phenomena.  Now,  that 
we  may  understand  the  mechanism,  if  we  may  so  speak,  of  this 
physiological  phenomenon,  let  us  exhibit  the  causes  which  pro- 
duce it,  and  endeavor  to  seek  for  a  satisfactory  explanation. 

Section  II.  Of  the  causes  and  of  the  expression  of  the  cry.-^^ 
"What  produces  the  first  cry?  It  is  generally  believed  to  be 
pain,  produced  by  new  sensations  which  the  infant  experiences  ; 
such  as  the  impression  of  the  air  upon  the  body  suddenly  expo- 
sed to  a  temperature  much  colder  than  that  to  which  it  has  been 
accustomed,  the  contact  of  the  clothes  or  of  the  hands,  the  action 
of  the  light  upon  the  sense  of  sight,  and  probably  by  the  intro- 
duction of  air  into  the  lungs,  which  are  now  for  the  first  time 
exposed  to  its  action. 

The  child  gives  well  marked  evidences  of  the  excitation  it  re- 
ceives, by  the  rapid  movements  of  the  limbs,  sometimes  by  sneez- 
ing, and  always  by  cries.  The  accoucheur  ought  to  be  particu- 
larly attentive  to  the  manner,  duration,  and  nature  of  the  cry, 
during  the  first  moments  of  extra-uterine  existence,  because  par- 
ticular modifications  form  a  suitable  index  of  the  complete  or  in- 
complete establishment  of  respiration,  as  well  as  of  the  healthy 
or  diseased  condition  of  the  lungs.  But  we  will  return  hereafter 
to  this  subject ;  let  it  suffice  for  the  present  to  observe  that  an  in- 
fant should  be  considered  as  vigorous  and  in  a  good  condition, 
when  the  cry  is  well  sustained,  sonorous,  and  easy ;  such  a  cry 


42  ON   THE    DISEASES   OP   INFANTS. 

is  always  the  result  of  a  deep  and  free  inspiration,  indicating,  ac- 
cordingly, the  existence  of  vigor  and  health.  We  sometimes, 
however,  see  children  of  a  full  size,  with  robust  limbs,  scarcely 
breathing,  and  crying  with  difficulty,  perish  from  asphyxia  or 
apoplexy;  whilst  others,  much  more  weak,  judging  from  the  ex- 
ternal appearance  of  their  bodies,  full  of  hfe,  if  we  consider  the 
power  of  their  cries,  undergo  without  danger  the  changes  which 
occur  so  suddenly  in  the  system,  in  passing  from  the  uterine  to 
the  extra-uterine  existence. 

When  these  sources  of  irritation  so  productive  of  new  sensa- 
tions are  removed,  the  cries  then  proceed  from  other  causes. 
Thus,  they  are  excited  by  some  want,  by  distress,  or  by  pain.  It 
is  important  to  be  able  to  distinguish  the  various  causes,  that  they 
may  either  be  mitigated  or  removed.  The  general  uneasiness 
which  a  child  experiences  after  being  rolled  in  its  envelope,  is 
often  the  cause  of  its  cries  ;  it  is  true,  that  the  general  practice  of 
bandaging  infants  as  was  formerly  the  custom,  has  ceased,  yet 
there  are  many  places  where  the  eloquent  voice  of  the  philoso- 
pher of  Geneva  has  not  reached,  and  we  may  see  almost  daily  at 
the  Hospice  des  Enfans  Trouves,  in  Paris,  the  sisters,  servant- 
maids,  or  nurses,  in  dressing  the  child,  often  make  it  more  like  a 
solid  packet,  than  clothe  it  in  such  a  manner  as  to  allow  of  mo- 
tion in  the  limbs,  or  of  free  respiration.  If  an  adult  should  be 
placed  in  a  bed  under  the  same  torture,  says  Rozen,  so  often  in- 
flicted on  children,  would  he  not  regard  it  as  an  insupportable 
torture  ?  but  we  are  destitute  of  pity  for  these  helpless  little  crea- 
tures. After  being  in  some  degree  habituated,  they  will  be  ena- 
bled to  support  for  a  time  the  compression  of  the  bandages,  and 
the  want  of  sleep,  more  imperious  than  are  all  the  other  sensa- 
tions, produces  a  momentary  calmness,  and  the  child  at  last 
yields  more  to  the  fatigue  it  has  undergone,  than  to  its  natural 
desire  for  sleep  ;  but  no  sooner  is  the  first  necessity  for  sleep  sat- 
isfied, than  the  uneasiness  again  distresses  it,  and  the  crying  is 
recommenced.  It  is  observed  in  the  wards  of  the  Hospice  des 
Enfans  Trouves,  when  one  child  begins  to  cry,  all  the  others 
follow  forthwith.  There  needs  but  one  to  disturb  the  repose  of  a 
whole  ward ;  and  all  being  awakened  by  the  crying  of  one,  they 
again  experience  the  uneasiness  or  pain  from  which  sleep  had 
for  a  short  time  relieved  them. 


ON    THE    DISEASES    OF    INFANTS.  43 

The  crying  may  sometimes  be  found  to  proceed  from  the 
uneasiness  which  the  child  experiences  from  a  portion  of  its 
clothes  or  the  bedclothes  being  badly  arranged ;  when  from  this 
cause,  it  may  easily  be  remedied  by  loosening  the  bandages  and 
otherwise  arranging  the  clothes.  We  may  also  remark  that 
when  an  infant  experiences  nothing  more  than  a  slight  uneasi- 
ness, it  only  cries  at  intervals,  and  that  it  is  calmed  by  the  least 
diversion. 

The  want  of  food  also  will  cause  a  young  child  to  cry.  We 
may  ascertain  whether  this  be  the  cause,  in  considering  the 
length  of  time  that  has  elapsed  since  it  has  sucked.  We 
should  not,  however,  in  every  instance  conclude  that  hunger 
has  produced  the  cries,  where  it  becomes  calm  upon  taking 
the  breast,  for  some  children  have  a  remarkable  voracity,  and 
will  not  for  a  moment  leave  the  breast.  The  stomach  in  such 
a  case  is  overloaded  with  milk,  rejects  almost  every  instant 
its  superabundant  load,  or  it  becomes  the  seat  of  an  inflamma- 
tion very  difficult  to  subdue.  Under  such  circumstances,  we 
should  use  the  greatest  care  to  regulate  the  hours  of  sucking, 
and  endeavor  by  other  means  to  calm  its  distress. 

Lastly,  pain  is  a  frequent  cause  of  crying.  The  cry  caused 
by  pain  is  remarkable  for  its  strength,  frequency,  and  obstinacy, 
and  may  be  known  by  the  particular  expression  of  the  face  with 
which  it  is  accompanied,  very  difficult  indeed  to  describe,  but 
which  may  be  easily  recognized  by  the  general  condition  of  the 
child,  such  as  palidness,  wasting,  and  an  aversion  to  the  breast. 
It  may  also  be  known  by  the  assemblage  of  such  symptoms  as  de- 
signate the  existence  of  disease  in  some  part  of  the  body.  The 
sound  and  form  of  the  cry  excited  by  pain,  are  likewise  influen- 
ced by  the  organs  affected ;  these  modifications  will  be  pointed 
out  below. 

Some  children  cry  without  our  being  able  to  discover  any 
cause,  and  notwithstanding  their  continual  restlessness  and  wake- 
fulness, they  are  observed  not  to  become  emaciated.  These 
children  are  distinguished  by  their  obstinate  cries,  among  all 
others  in  the  wards  of  the  Hospice  des  Enfans  Trouves,  and 
they  well  deserve  the  appellation  given  them  by  their  nurses,  of 
wicked  children.  This  continual  excitement  proceeds,  without 
doubt,  from  a  highly  exalted  sensibility,  existing  much  more  in 


44  ON   THE    DISEASES    OF    INFANTS. 

them  than  in  others  ;  and  crying  being  the  expression  of  an  un- 
easiness which  it  is  natural  in  this  way  to  divert. 

It  is  important  not  to  lose  sight  of  what  passes  in  the  circula- 
tory and  respiratory  organs  while  the  child  is  crying.  "We  have 
already  seen  that  the  physical  agents  of  respiration  are  in  a  kind 
of  spasmodic  condition,  whence  results  a  considerable  distur- 
bance in  the  pulmonary  circulation.  The  return  of  the  blood  to 
the  left  cavities  of  the  heart,  is  attended  with  some  distress,  it 
remains  stagnant  in  the  lungs,  and  a  reflux  occurs  in  the  right 
cavities,  and  from  thence  in  the  venous  system  generally  ;  a  con- 
gestion thereby  exists,  producing  the  violet  tint  so  common  in 
children  that  cry  with  violence.  I  have  seen  children  undergo 
a  momentary  asphyxia  during  a  fit  of  hard  crying.  The  lungs, 
heart,  and  even  the  brain,  are  exposed  to  congestions  which  may 
be  fatal ;  and  we  ought,  consequently,  to  endeavor  to  calm  or  arrest 
the  cries  of  children.  Rozen  has  given  us  excellent  advice  upon 
this  subject.  "  All  the  art  of  tranquillizing  the  child,"  says  he, 
"consists  in  removing  the  occasions  of  his  cries,  and  to  divert 
him  by  some  object  that  will  fix  his  attention,  so  that  he  will  no 
longer  think  of  it,  or  at  least  that  his  attention  may  not  be  farther 
attracted  by  the  cause  of  his  uneasiness." 

In  order  to  avoid  the  occasion  and  to  prevent  the  return  of  the 
crying,  I  think  it  would  be  proper  to  regulate  the  hours  of  suck- 
ing, to  accustom  the  child  to  sleep  in  the  midst  of  noise,  to  have 
it  lightly  clothed,  to  maintain  such  a  temperature  in  the  apart- 
ment that  it  is  neither  too  hot  nor  too  cold,  and  finally,  to  quiet  its 
restlessness  by  the  sound  of  some  soft  musical  instrument,  but 
more  particularly  by  the  most  common  and  natural  means  of 
singinof,  a  mode  so  easy  and  natural  as  to  have  become  popular. 

After  having  given  the  general  history  of  the  cry  of  new- 
born children,  it  now  remains  for  us  to  consider  the  varieties 
of  form,  tone,  and  duration,  according  to  various  diseases. 

Section  III.  Alterations  and  varieties  of  the  cry  of  young 
children. — The  cry  exhibits  varieties  in  the  form,  tone,  and 
duration. — The  form  may  be  incomplete,  laborious,  and  smoth- 
ered.— The  tone  may  be  acute,  grave,  husky,  and  tremulous. — 
The  duration  may  be  short  or  frequent,  and  interrupted. 

1st.  Alterations  in  the  form  of  the  cry. — By  incomplete  cry, 
I  mean  that  in  which  only  one  part  is  heard.     Thus  the  reprise 


ON   THE    DISEASES    OF    INFANTS.  45 

is  sometimes  altogether  silent,  whilst  the  cry  is  distinct;  on  the 
other  hand,  the  sound  of  the  reprise  alone  exists.  The  former 
occurs  when  the  lungs  are  healthy  and  perfectly  permeable  to 
the  air ;  the  child  does  not  use  all  its  muscular  efforts  during 
inspiration,  so  that  the  air  traverses  the  glottis  without  any  noise, 
and  produces  none  except  when  it  passes  through  on  expiration. 
This  cry  is  of  little  consequence  ;  it  is  ordinarily  observed  in  those 
children  who,  without  being  really  sick,  are  very  small  and 
feeble  ;  but  it  is  .  not  so  with  the  smothered  cry.  This  is  almost 
always  a  certain  indication  of  pulmonary  engorgement  or  of 
inflammation.  As  I  do  not  wish  to  advance  any  opinion  not 
founded  on  facts,  I  will  exhibit  a  summary  of  the  observations 
which  have  led  me  to  regard  as  demonstrated  each  of  the  asser- 
tions which  I  propose  to  make. 

I  have  noticed  twenty  children  where  the  reprise  alone  was 
heard  with  distinctness,  while  the  cry  was  smothered.  Six  of 
these  were  born  before  the  full  time,  (from  the  fifth  to  the  seventh 
month ;)  in  three  of  these  cases,  a  day  after  birth,  the  air 
appeared  not  to  have  penetrated  the  lungs,  for  when  these  were 
put  into  a  vessel  of  water,  they  soon  sunk  to  the  bottom,  whether 
they  were  immersed  in  one  mass,  or  previously  separated  in 
parts.  In  three  other  children,  prematurely  born,  the  air  had 
passed  into  a  portion  of  the  pulmonary  parenchyma,  but  the 
greater  part  was  compact,  without  crepitation,  and  engorged  with 
blood ;  in  the  remaining  fourteen,  the  lungs  were  much  engorged 
and  hepatized,  producing  the  impression  that  the  air  could  not 
have  penetrated  these  organs  except  with  the  greatest  difficulty. 

From  these  cases  we  can  draw  our  first  conclusions  in  refer- 
ence to  the  cry  of  a  new-born  child;  it  is,  that  in  those  instances 
in  which  the  reprise  alone  is  heard,  it  is  very  probable  that  the  air 
does  not  penetrate,  has  not  penetrated,  or  has  penetrated  but  very 
slightly  into  the  lungs ;  this  sign,  joined  with  percussion  and 
auscultation,  will  furnish  a  suitable  diagnosis  of  the  disease  of  the 
lungs.  And  when  physicians  are  summoned  to  give  their  testi- 
mony upon  the  viability  of  a  child,  they  ought  to  inform 
themselves  particularly  as  to  the  nature  of  the  cry.  A  child  that 
has  not  respired  may  cry,  but  its  cry  will  be  of  a  peculiar  kind, 
which  should  be  observed  with  great  care.  Perhaps  in  this 
manner  we  might  avoid  contradictions  so  often  occurring  in  a 


* 
46  ON     THE    DISEASES    OF    INFANTS. 

court  of  justice  in  the  examination  of  physicians,  who  by  the 
docimasia  of  the  lungs,  state  that  an  infant  has  not  respired, 
while  the  parents  and  midwives  affirm  that  they  saw  the  child  in 
question  open  its  mouth,  breathe,  and  cry. 

The  laborious  cry  is  easily  recognized  by  the  efforts  made  by 
the  child,  the  painful  expression  of  the  face,  the  difficulty  expe- 
rienced in  the  attempts  to  expel  the  air  from  the  lungs,  and  by 
the  peculiarity  of  its  termination,  as  it  almost  always  ends  in  a 
sort  of  dying  sound,  not  being  entirely  sustained  throughout. 
The  cause  of  this  cry  is  not  always  an  affection  of  the  respira- 
tory organs.  In  six  children,  where  I  was  struck  with  the  ex- 
treme difficulty  of  crying,  and  where  both  parts  of  the  cry  were 
heard,  two  were  affected  with  pleuro-pneumonia  with  effusion 
in  the  pleura,  one  with  a  gelatinous  softening  of  the.  stomach,  the 
fourth  with  cephalitis,  the  fifth  with  acute  peritonitis,  and  the 
sixth  with  well-marked  pericarditis.  It  appears  as  if  the  cry 
then  derived  its  expression  from  the  distress  endured  by  the 
child  ;  the  painful  cry  which  the  observer  can  detect  at  the 
bed-side  better  than  I  can  describe  it  here,  will  be  but  the 
necessary  result,  or  at  least  the  probable  evidence,  of  the 
existence  of  a  serious  disease  in  some  part  of  the  body. — 
The  smothered  cry  is  sufficiently  defined  by  its  name, — no 
sound  is  emitted.  The  alternate  motion  of  inspiration  and 
expiration  gives  rise  to  a  double  respiratory  murmur,  with 
which  there  is  sometimes  mingled,  at  intervals,  a  slight  sound 
of  voice  more  or  less  acute.  The  smothering  of  the  cry  may 
arise  from  many  causes.  In  eighteen  children  in  whom  the  cry 
was  entirely  smothered,  there  were  thirteen,  who,  having  at  first 
respired  and  cried  perfectly  free,  were  attacked  with  a  severe 
pneumonia,  and  during  the  last  days  of  their  life  their  cries 
were  entirely  lost.  On  examining  the  bodies  of  these  children 
after  death,  both  lungs  in  each  of  them  were  found  hepatized, 
the  larynx  and  bronchiae  very  much  inflamed,  and  the  large 
vessels  and  heart  considerably  congested  with  blood.  In  two  others 
the  larynx  alone  was  violently  inflamed,  and  the  lungs  crepitated 
slightly ;  and  in  the  remaining  three,  who  were  born  quite  feeble, 
the  respiration  never  had  been  well  established,  and  the  cry  not 
at  all  heard ;  in  two  of  these  the  respiratory  organs  exhibited  the 
same  sanguineous  congestion  as  the  preceding ;  the  third  was 


ON  THE  DISEASES  OP  INFANTS.  47 

restored  by  the  application  of  a  leech  to  each  axilla ;  the  cry- 
was  gradually  established,  and  the  child  improved  for  a  few  days, 
and  then  died  also.  Upon  examining  the  body,  congestion  in  the 
back  part  of  each  lung  was  observed.  It  often  happens  that  the 
cry  of  a  child  just  born  is  entirely  smothered,  and  is  not  restored 
except  in  proportion  as  the  respiration  is  free  and  full.  The  cry 
also  becomes  smothered  in  the  distress  accompanying  the  disease 
of  long  duration,  and  which  has  reduced  the  child  to  extreme 
weakness ;  when  at  the  same  time  the  Fades  Hippocratioa 
is  observed,  it  is  a  certain  sign  of  approaching  death.  From 
what  we  have  seen,  the  smothered  cry  is,  like  the  incomplete,  a 
very  probable  symptom  of  congestion  and  of  inflammation  of  the 
lungs,  and  may  be,  also,  of  inflammation  of  the  glottis  and  bron- 
chiae. 

2d.  Alterations  in  the  tone  of  the  cry. — It  is  necessary  on  this 
subject  to  notice  with  great  care  whether  or  not  it  is  the  sound  of 
the  reprise  or  the  proper  cry,  that  is  altered.  That  which  is 
called  the  acute  cry,  is  usually  produced  by  the  eflbrt  at  renewal 
becoming  predominant  and  loud.  Any  one  may  be  satisfied  on 
this  point  by  examining  a  child  suffering  from  a  severe  anginose 
disease,  or  from  the  strangulation  produced  by  the  presence  of  a 
foreign  body  in  the  larynx,  by  malignant  sore  throat,  or  croup. 
This  sound,  which  all  authors  compare  to  the  crowing  of  a 
young  cock,  and  which  is  so  distinct  in  croup,  is  nothing  more 
than  the  reprise  or  effort  at  renewal  becoming  louder  and  sharper, 
and  also  interrupted  and  jerked,  by  spasmodic  movements  of 
which  the  larynx  becomes  the  seat  during  the  course  of  this 
disease.  In  general,  the  reprise  of  the  cry  becomes  acute  every 
time  the  tonsils  or  larynx  experience  any  irritation.  When  the 
child  has  cried  a  great  deal,  and  consequently  has  irritated  the 
organs  of  voice,  the  reprise  soon  assumes  a  very  acute  sound, 
whilst  the  proper  cry  ceases  to  be  heard.  The  same  occurs 
when  the  inflammation  of  the  membrane  lining  the  mouth  is  pro- 
pagated to  the  tonsils  and  larynx.  I  have  examined  the  bodies 
of  three  children,  who,  although  they  had  not  been  affected  with 
croup,  had  nevertheless  exhibited  the  acute  cry,  the  reprise 
with  the  characteristic  interruption,  very  closely  resembling 
the  crowing  of  a  young  cock.  In  two  of  them,  where  there  had 
been  a  violent  affection  of  the  throat,  the  inflammation  extended 


48  ON   THE    DISEASES   OP    INFANTS. 

far  down  the  trachea.  In  the  third  the  tonsils  were  covered  with 
a  thick  coating  of  mucus,  which  also  surrounded  the  borders  of 
the  glottis,  but  the  trachea  was  free  from  it  and  the  lungs  were 
healthy. 

Both  parts  of  the  cry  may  be  very  acute  without  the  existence 
of  a  particular  lesion  in  the  organs  of  voice.  It  is  known  that , 
M.  Maunoir,  of  Geneva,  has  heretofore  remarked  the  peculiar 
sound  of  the  cry  of  a  child  affected  with  acute  hydrocephalus, 
and  which  he  has,  I  believe,  designated  by  the  name  of  "hydren- 
cephalique."  It  probably  is  the  effect  of  the  excessive  pain  en- 
dured by  the  child,  whose  head  is  distended  by  a  continually  in- 
creasing accumulation  of  serum  in  the  ventricles  of  the  brain. 

I  think,  therefore,  that  we  ought  to  lay  down  as  a  principle, 
that  the  acute  cry  is  almost  always  produced  by  the  reprise,  the 
tone  of  which  is  altered,  and  that  this  particular  alteration  of 
the  cry  in  children  is  more  often  the  sign  of  laryngitis  or  of 
laryngo-trachitis  than  of  inflammation  of  the  lungs. 

The  grave  or  sonorous  cry  furnishes  but  few  indications  of 
disease.  I  have  seen  but  one  child  that  was  remarkable  for  a 
sonorous  and  harsh  cry.  This  was  affected  with  a  slight  ente- 
ritis, which  was  very  promptly  cured.  I  can  only,  therefore,  point 
out  the  peculiarity  of  this  cry,  without  being  able  to  assign  any 
cause  for  its  existence. 

The  husky  cry  is  often  observed  in  catarrhal  affections.  The 
mucous  rale  is  heard  at  the  same  time.  It  appears  as  if  the  thick 
mucus  which  obstructs  the  bronchias,  hinders  the  air  from  circu- 
lating freely  through  the  tubes  in  its  passage  to  the  glottis,  at  the 
opening  of  which  there  is  not  a  sufficient  quantity  passing  at 
one  time  to  produce  a  clear  and  resounding  effect.  This  altera- 
tion belongs  more  particularly  to  the  proper  cry  than  to  the  re- 
prise, which  usually  retains  its  natural  sound,  although  the  con- 
trary may  exist.  In  twelve  new-born  infants,  where  the  cry  was 
of  this  character,  the  bronchiae  of  four  of  them  were  filled  with 
mucus,  and  a  violent  anginose  affection  existed  in  the  other  two. 
The  husky  cry  may  then  be  considered  as  an  indication  of  an 
affection  of  the  bronchise  or  larynx.  It  may  likewise  be  observed 
in  the  sequel  of  simple  or  of  pseudo-membranous  phlegmasias  of 
these  parts.  A  child  that  has  had  the  good  fortune  to  survive  an 
attack  of  croup,  retains  for  a  long  time  an  alteration  in  the  sound, 


ON   THE    DISEASES   OF    INFANTS.  49 

both  of  the  voice  and  cries,  wliich  remain,  as  has  been  observed 
by  authors,  almost  always  husky. 

There  is  one  pecuhar  cry  of  which  I  have  observed  but  three 
cases,  and  which,  by  reason  of  its  trembling  and  jerking  manner, 
may  be  compared  to  the  bleating  of  a  goat.  The  reprise  is  more 
distinctly  heard  than  the  cry ;  both  are  faint,  and  have  the  pecu- 
liar sound  which  I  have  mentioned.  The  three  children  that 
exhibited  this  cry,  were  of  the  age  of  eight  days,  of  three  weeks, 
and  of  four  months.  They  died  from  chronic  enteritis  ;  and 
in  addition  to  this,  the  glottis  was  csdematous,  and  presented  the 
appearance  of  oedematous  inflammation,  so  that  I  have  been  led  to 
believe  that  the  tremulous  cry  is  the  distinctive  sign  of  oedema- 
tous angina.  I  advance  this  opinion,  however,  with  the  caution 
which  should  accompany  a  conclusion  drawn  from  so  few  facts. 

3d.  Alterations  in  the  duration  of  the  cry. — Whatever  may 
accelerate  the  movements  of  respiration,  will  also  cause  a  rapidi- 
ty in  the  cry  ;  the  two  parts  composing  it  following  with  great 
rapidity,  and  three  or  four  cries  preceding  one  reprise.  This 
kind  of  cry  is  usually  produced  by  violent  and  sudden  pain,  such 
as  that  arising  from  the  pricking  of  a  pin,  or  from  burning  the 
mouth  in  drinking.  It  is  also  to  be  observed  in  colic,  peritonitis, 
and  other  abdominal  pains. 

The  interrupted  cry  exists  in  angina  suffocativa,  an  affection 
which  is  more  often  a  true  disorder  of  the  nerves  of  the  respira- 
tory apparatus.  This  cry  closely  resembles  that  which  charac- 
terizes croup  ;  it  is  in  both  cases  owing  to  a  change  in  the  sound 
of  the  reprise ;  but  both  parts  of  the  cry  can  be  distinctly  heard 
in  the  former  affection,  whilst  in  croup,  the  cry  is  entirely  re- 
placed by  a  blowing  sound  which  succeeds  each  reprise.  The 
interrupted  or  singultous  cry,  is  also  very  irregular ;  it  is  produ- 
ced and  maintained  by  causes  which  render  the  respiration  spas- 
modic, and  it  indicates  great  disorder  of  the  immediate  organs  of 
voice.  I  have  seen  it  in  the  highest  degree  in  an  infant  four 
months  old,  who  died  after  exhibiting  symptoms  analogous  to 
those  of  croup.  Upon  examining  the  body,  all  the  disease  found 
was  a  mass  of  crude  tubercles,  about  the  size  of  a  nut,  in  the 
posterior  mediastinum,  strongly  compressing  the  trachea  at  the 
commencement  of  the  bronchiee.  The  diameter  of  the  trachea 
was  reduced  about  one  half,  by  the  flattening  it  had  undergone, 


50  ON    THE    DISEASES    OP    INFANTS. 

SO  that  the  air  could  not  pass  through  it  without  great  diffi- 
culty. 

We  may  draw  from  the  preceding  considerations,  inferences 
which  ought  not  to  be  forgotten  in  the  semeiology  of  diseases  of 
children  at  the  breast.  These  are,  that  the  changes  in  the  proper 
cry,  usually  indicate  an  affection  of  the  lungs  or  bronchise,  whilst 
the  changes  in  the  reprise  are  ordinarily  evidences  of  an  affection 
of  the  trachea  or  larynx.  If  experience  confirm  this  rule,  to 
which  there  may  still  be  exceptions,  it  will  be  admitted  that  the 
distinction  we  have  made  of  two  parts  to  the  cry,  is  not  a  frivolous 
one,  since  it  may  be  made  practically  useful. 

As  to  the  different  varieties  of  the  cry  of  the  new-born  child, 
of  which  I  have  just  treated,  there  is  no  doubt  that  with  a  little 
imagination  and  the  invention  of  new  words,  they  might  be  mul- 
tiplied almost  ad  infinitum ;  but  I  have  confined  myself  to  the 
distinctions  already  made,  because  I  think  it  is  easier  to  describe 
the  modifications  which  the  ear  can  detect.  When  we  treat  of  the 
diseases  affecting  the  organs  of  phonation  in  particular,  we  will 
make  application  of  each  of  the  varieties  and  alterations  of  the 
cry,  which  have  hitherto  been  considered  in  a  general  manner. 

Article  II. — Expression  of  the  face. 

Next  to  the  cry,  the  expression  of  the  face  is  one  of  the  princi- 
pal means  by  which  a  child  manifests  the  sensations  it  experien- 
ces. The  physiognomy  of  a  very  young  child  does  not  exhibit 
to  the  eyes  of  people  generally,  a  well  marked  expression  ;  yet  if 
we  judge  by  the  sentiments  it  inspires,  we  must  admit  that  it  ex- 
presses tenderness  and  amiability.  But  it  is  probably  more  cor- 
rect to  say,  that  we  judge  variously  of  the  physiognomy  of  chil- 
dren, and  of  all  other  things  which  attract  our  attention  in  them,  ac- 
cording to  our  particular  dispositions :  and  the  abstract  idea  we  form 
of  beauty  or  deformity,  very  materially  influences  our  judgment. 
The  physician  should  not  be  influenced  by  the  sensations  thus 
produced,  for  it  is  the  result  of  a  very  superficial  examination. 
He  should  attempt  to  understand  the  changes  which  occur,  if  he 
is  desirous  of  discovering  in  the  lineaments  of  the  face,  the  ex- 
pressions indicating  the  existence  of  any  want  or  distress.  In 
order  to  add  to  our  knowledge  of  the  symptoms  of  disease  in 
children,  M.  Jadelot  has  proposed  a  fhysiognomical  semeiology^ 


ON   THE    DISEASES    OF    INFANTS.  51 

by  which  he  has  rendered  a  valuable  service  to  science,  since  this 
theory  is  capable  of  shedding  some  light  on  the  diagnosis  of  dis- 
eases of  children,  a  subject  always  obscure.  M.  Jadelot  has  not 
as  yet  given  publicity  to  this  subject,  otherwise  than  to  those 
who  have  been  in  the  habit  of  accompanying  him  in  his  visits ; 
nothing  therefore  has  been  published  respecting  it,  except  by  M. 
Eusebe  de  Salle,  in  some  preliminary  remarks  appended  to  Un- 
derwood's Treatise  on  diseases  of  children.  "  During  the  first 
months  of  life,"  says  this  author,  "the  face  of  the  child  scarcely 
presents  any  thing  more  than  a  shapeless  mass,  when  but  few 
remarkable  lineaments  can  be  distinguished.  Yet  acute  diseases 
will  produce  evident  modifications  in  it.  These  alterations  will 
be  more  manifest  in  chronic  diseases."  It  is  from  the  first  den- 
tition to  puberty,  according  to  M.  Eusebe  de  Salle,  that  we  may 
derive  assistance  from  physiognomical  semeiology. 

From  this  it  appears  that  M.  Jadelot  has  not  applied  his  new 
theory  to  diseases  of  children  at  the  breast.  There  is  therefore 
a  deficiency  to  be  supplied,  and  as  we  do  not  agree  with  the 
commentator  of  Underwood,  in  thinking  that  the  face  of  young 
children  presents  no  remarkable  lineaments,  we  will  endeavor  to 
point  out  the  changes  which  occur,  and  the  indications  they  fur- 
nish. 

In  a  state  of  quiet  and  health,  the  face  of  the  child  presents  no 
wrinkles,  the  bony  prominences  do  not  appear,  the  cheeks  are 
round,  and  there  is  scarcely  any  expression  in  the  physiognomy; 
but  no  sooner  is  it  under  the  influence  of  pain  or  of  joy,  than 
there  occurs  a  very  remarkable  change  in  the  physiognomy. 

Pain,  at  least  during  the  first  month,  is  the  only  sensation  an 
infant  can  experience,  and  the  enjoyment  resulting  from  the 
exercise  of  all  its  functions  is  rather  the  absence  of  pain  than 
the  existence  of  pleasure,  such  as  we  experience.  We  have  seen 
that  an  infant  while  crying  exhibits  certain  wrinkles  at  the  root 
of  the  nose  and  at  the  external  angles  of  the  eyes,  the  mouth 
opens,  and  the  muscles  of  the  face,  for  the  most  part,  are  in  a 
state  of  alternate  contraction  and  relaxation.  These  are  observed 
from  the  very  mornent  of  birth ;  and  that  particular  expression 
which  we  have  said  results  from  the  eflbrts  of  hurried  respiration, 
is  a  first  symptom,  which  must  be  observed  with  care,  as  it  may 
lead  us  farther.     Let  u^  for  a  moment  endeavor  to  separate  the 


52  ON   THE    DISEASES    OF    INFANTS. 

cry  which  ordinarily  accompanies  this  movement  of  the  face,  and 
compare  the  different  wrinkles  thus  produced  with  those  we 
observe  in  an  adult  suffering  from  great  distress.  The  upper 
lip  will  be  seen  to  wrinkle  and  elevate  itself  in  the  middle, 
vertical  and  horizontal  wrinkles  to  be  delineated  at  the  root  of 
the  nose  or  to  spread  in  front,  the  eyelids  to  approach,  and  a 
number  of  wrinkles  to  appear  at  the  external  angle  of  the  eye, 
or  to  be  delineated  in  a  circular  manner  in  the  direction  of  the 
orbicularis-palpebrarum  muscle.  It  is  by  traits  such  as  these,  that 
painters  indicate  grief,  and  such  are  the  traits  which  are  observed 
in  an  infant  that  cries  ;  and  finally,  such  are  the  marks  which 
characterize  pain  in  the  child  just  born.  If  to  these  the  physi- 
cian adds  other  circumstances  to  perfect  his  judgment,  it  will  be 
easily  understood  that  the  marks  of  distress  may  be  recognized  in 
very  young  children.  I  have  convinced  myself,  besides,  of  the 
truth  of  what  I  have  advanced  by  examining  children  that  have 
been  accidentally  pricked,  or  that  have  been  burned  by  giving 
them  drink  too  hot. 

It  is  easy  to  explain  how  the  expression  of  distress  may  be 
exhibited  by  the  same  muscular  contractions  produced  by  the 
acceleration  and  difficulty  of  respiration.  The  painful  sensa- 
tions always  act  sympathetically  on  the  organs  of  circulation  and 
respiration,  and  the  entire  nervous  circle  described  by  Sir  Charles 
Bell,  experiences  by  irradiation  a  sudden  excitement,  whence 
results  the  assemblage  of  thoracic  and  facial  contractions  seen  in 
a  child  while  crying  and  suffering ;  excessive  joy  will  likewise 
produce  a  commotion  in  the  circulatory  organs,  but  it  suspends 
much  sooner  than  it  eccelerates  their  movements,  and  it  is  well 
Imown  that  excessive  joy  will  cause  syncope  quicker  than  exces- 
sive grief.  It  is  also  well  known  that  in  a  severe  operation  the 
patient  does  not  usually  faint  away  during  the  excess  of  pain, 
but  that  syncope  generally  occurs  when  he  ceases  to  feel  the 
cutting  of  the  instrument.  The  cries,  sobbing,  and  sense  of 
suffocation,  which  those  experience  who  suffer  from  some  distress, 
show  the  connexion  existing  between  the  sentiment  of  grief 
and  the  convulsive  agitation  of  the  muscles  of  the  thorax  and  face. 
In  this  manner  can  be  explained  why  the  contractions  of  the  face 
which  occur  in  crying,  are  the  same  with  those  that  constitute 
the  expression  of  grief. 


ON    THE    DISEASES    OF    INFANTS.  53 

This  preliminary  point  being  established,  we  will  be  able  to 
take  for  an  object  of  comparison  the  painful  expression  of  face 
which  we  have  just  described,  and  to  regard  as  a  symptom  of 
pain  each  modification  of  the  physiognomy  having  any  relation  to 
this  expression.  The  evidences  of  distress,  more  or  less  defined, 
can  be  traced  in  an  infant  in  the  cradle,  where  there  exists  a  dull 
pain  from  chronic  disease,  general  uneasiness,  or  difficult  diges- 
tion :  sometimes  they  are  just  visible,  imparting  to  the  face  of  the 
child  a  peculiar  expression,  which  will  not  escape  an  attentive 
observer,  difficult  indeed  to  describe,  but  easily  understood  when 
seen ;  it  is  like  a  cloud,  if  I  may  be  allowed  the  metaphor,  cover- 
ing and  obscuring  the  face  of  the  infant.  These  expressions  are 
much  more  strongly  marked  under  some  circumstances,  and  then 
cannot  be  misunderstood.  They  frequently  appear  upon  the 
waking  of  the  infant,  and  will  continue  some  minutes  before  the 
crying  commences.  In  cases  of  continued  pain,  as  in  chronic 
affections  of  the  abdomen,  they  are  more  or  less  perceptible  or 
modified,  they  continue  permanent;  and  if  to  them  are  added 
languor  and  depression  when  the  skin  becomes  pale  and  shrunk, 
we  shall  have  a  type  of  the  painful  expression  :  the  face  then 
bears  the  seal  of  pain ;  the  same  occur  in  acute  hydrocephalus 
and  in  pellicular  inflammation  of  the  air  passages.  We  are  thus 
made  acquainted  with  the  expression  of  pain  in  children,  the 
first  step  in  the  study  of  their  diseases. 

In  studying  the  particular  diseases  of  infancy,  we  shall  see  how 
this  expression  is  modified  under  the  influence  of  the  different 
organs,  and  we  shall  then  apply  M.  Jadelot's  theory  as  far  as 
possible. 

The  face  of  the  child  may  also  express  its  feeling  of  joy. 

Infants  rarely  smile  before  they  are  three  weeks  old.  I  have 
seen  many,  however,  take  part  in  the  attempts  often  made  to  ob- 
tain a  smile,  but  usually  it  is  not  until  about  the  age  of  one  month 
that  an  infant  really  begins  to  laugh.  The  expression  of  the 
face  is  then  too  well  known  for  me  to  attempt  its  description,  and 
all  physiologists  have  spoken  of  the  general  unfolding  of  the  linea- 
ments of  the  face  which  constitutes  the  expression  of  happiness 
and  joy,  and  have  contrasted  this  condition  with  the  state  of 
general  contraction  existing  in  pain.  "  In  pain,"  says  Cabanis, 
"the  animal  retires  entirely  within  himself,  as  if  to  present  the 


54  ON  THE  DISEASES  OP    INFANTS. 

smallest  possible  surface ;  in  pleasure,  all  the  organs  seem  to 
unfold,  as  it  were,  to  receive  it  in  all  parts." 

This  expression  of  joy  in  children  becomes  more  marked  in 
proportion  as  they  advance  in  age  ;  at  first  it  consists  in  a  simple 
movement  of  the  lips  ;  this  movement  increases,  and  is  afterwards 
followed  by  reiterated  bursts  of  laughter.  This  expression  of  the 
physiognomy  is  less  useful  for  us  to  know,  and  we  have  been  at 
less  pains  to  study  its  modifications,  our  task  being  limited  to  a 
esearch  for  some  external  sign  by  which  we  may  be  enabled  to 
discover  the  source  and  nature  of  the  evils  experienced  by  man.  at 
an  age  when  the  language  of  pain  can  only  be  comprehended 
and  interpreted  with  great  difficulty. 

To  recapitulate.  The  physiognomy  of  an  infant  expresses — 
1st,  Pain :  exhibiting  the  same  contractions,  more  or  less  marked, 
as  those  which  accompany  the  cry;  2dly,  Its  healthy  condition  : 
no  well  defined  contraction  is  then  manifested ;  the  lineaments 
appear  to  dilate  and  unfold. 

But  besides  these,  the  face  of  a  child  may  have  a  peculiar  ex- 
pression according  as  the  encephalic,  thoracic,  or  abdominal  organs 
are  diseased.  A  great  number  of  observations  will  be  necessary 
to  demonstrate  this  fact.  On  this  account  we  will  not  at  this 
time  point  out  the  various  expressions  of  the  physiognomy  in 
different  diseases,  but  will  leave  them  until  they  come  pro- 
perly under  consideration  ;  when  it  will  be  seen  that  our  ob- 
servations are  not  to  be  directed  solely  to  the  contraction  of  the 
lineaments  of  the  face,  but  also  to  the  shades  of  color,  which  are 
by  no  means  to  be  neglected  in  the  study  of  the  diseases  of  infancy. 


CHAPTER    VII. 

OP   THE    STATE    OF   THE    PULSE    IN    CHILDREN. 

All  authors  agree  in  the  opinion  that  the  pulse  in  children  is 
much  more  frequent  than  in  adults  ;  this  is  true  in  the  greatest 
number  of  cases ;  it  is,  however,  subject  to  many  exceptions, 
and  I  have  often  been  surprised  to  find  the  pulse  of  a  newly  born 
child  nearly  as  slow  as  that  of  some  old  men,  in  whom  the  play 


ON   THE    DISEASES    OP    INFANTS.  55 

of  the  circulatory  apparatus  is  altered  or  diminished  by  the  de- 
velopment of  some  organic  lesion. 

As  it  is  important  to  have  fixed  ideas  on  the  condition  of  the 
pulse  in  children,  since  this  symptom  enables  us  to  make  a  pro- 
per diagnosis  of  their  diseases,  I  will  exhibit  the  result  of  my 
researches  on  this  subject.  I  first  directed  my  attention  to  the 
frequency,  that  is  to  say,  to  the  number  of  pulsations  in  a  minute, 
and  afterwards  considered  it  with  reference  to  its  other  characters. 

I  will  here  remark  that  it  is  very  difficult  to  count  the  beat  of 
the  pulse  with  exactness  in  new-born  children,  because  the  pulsa- 
tions sometimes  intermingle  with  each  other,  so  that  but  one  is 
often  counted  where  there  are  two.  And  again,  it  not  unfre- 
quently  happens  that  some  beats  are  imperceptible  under  the 
fingers  of  the  observer,  and  they  thus  escape  his  observation. 
Besides,  it  is  not  uncommon  to  find  an  artery  vibrating  twice 
under  the  finger,  as  occurs  in  the  decrotic  pulse  of  adults,  by  which 
two  pulsations  may  be  counted  for  one  ;  and  if  to  this  be  added 
the  difficulty  of  finding  the  artery  in  the  plump  arm  of  a  young 
infant,  and  the  still  greater  difficulty  of  keeping  the  wrist  fixed 
for  any  length  of  time,  it  will  be  easily  conceived  that  a  great 
degree  of  embarrassment  always  attends  the  counting  of  the  pulse 
of  a  young  infant.  The  following  is  the  best  mode  of  ascertain- 
ing it. 

The  physician  ought,  if  possible,  to  avoid  grasping  and  fixing 
the  arm  of  the  child  with  his  hand,  as  continual  motion  will  then 
be  made  to  relieve  it  from  the  compression  of  the  fingers ;  it  is 
much  better  to  permit  the  arm  to  remain  free,  and  to  apply  tho 
fore-finger  in  the  track  of  the  radial  artery ;  it  will  not  be  dis- 
covered until  after  a  little  search  ;  at  the  same  time  care  should 
be  taken  that  it  be  not  strongly  compressed,  as  it  might  thereby 
become  flattened  and  its  pulsation  rendered  imperceptible ;  after 
having  felt  a  few  beats,  the  pressure  of  the  finger  ought  to  be 
gradually  diminished  until  the  artery  is  permitted  to  dilate  to  its 
full  volume.  I  have  remarked  that  it  is  much  easier  to  find  the 
artery  by  applying  the  index  finger  alone,  than  by  placing  the 
first  three  fingers  on  the  track  of  the  artery  as  is  recommended  in 
adults.  The  finger  can  in  the  same  manner  be  applied  to  the 
temporal  artery. 

Finally,  if  the  beat  of  the   pulse  is   too  much   hurried,  too 


66  ON   THE    DISEASES   OF    INFANTS. 

obscure,  or  difficu]  t  to  be  accurately  distinguished,  the  observer 
may  be  able,  with  the  aid  of  the  stethoscope  or  the  hand,  to  count 
the  movements  of  the  heart,  a  method  often  employed. 

The  advice  just  given  in  relation  to  the  examination  of  the 
pulse  in  new-born  children  may  appear  to  some  persons  quite 
futile,  but  its  importance  will  be  better  understood  by  those 
ph^^sicians  who,  like  me,  have  known  the  difficulty  experienced  in 
obtaining  any  satisfactory  information  from  the  pulse  of  very 
young  children.  It  is  only  with  the  assistance  of  all  these  pre- 
cautions that  I  have  been  able  to  establish  the  following  results. 

In  forty  children,  aged  from  one  to  ten  days,  and  apparently  in 
good  health,  there  were  eighteen  where  the  pulse  beat  less  than 
eighty ;  in  two,  it  beat  eighty-six  ;  in  one,  eighty-nine  ;  in  four, 
one  hundred;  in  ten,  from  one  hundred  and  ten  to  one  hundred 
and  twenty-five ;  in  one,  one  hundred  and  thirty ;  in  two,  one  hun- 
dred and  forty-five ;  in  two,  one  hundred  and  fifty ;  in  one,  one  hun- 
dred and  eighty.  Thus  it  appears  that  there  were  as  many  chil- 
dren in  whom  the  pulse  exhibited  about  the  same  numberof  beats 
as  is  usually  observed  in  an  adult,  as  there  were  of  those  in 
whom  the  pulse  beat  with  much  greater  rapidity ;  and  I  am  confi- 
dent they  presented  no  symptom  of  disease. 

In  thirty-five  children,  aged  from  one  to  two  months,  there 
were  fourteen  where  the  pulse  never  exceeded  eighty  to  eighty- 
five  ;  in  one  of  them  it  was  as  low  as  sixty  to  sixty-two.  Two 
had  ninety  pulsations  ;  two  others,  ninety-four  and  ninety-five  ; 
five,  one  hundred  and  ten ;  two,  one  hundred  and  twelve  ;  two 
others,  one  hundred  and  fourteen  ;  seven,  one  hundred  and  twen- 
ty-five to  one  hundred  and  thirty  ;  three,  one  hundred  and  forty  ; 
one,  one  hundred  and  forty-seven  to  one  hundred  and  fifty.  We 
again  see  here,  a  number  of  children,  with  pulsations  correspond- 
ing in  number  with  those  of  an  adult ;  but  such  was  not  the 
case  in  the  instances  which  follow. 

In  eighteen  children,  aged  from  two  to  three  months,  there 
were  fourteen  where  the  pulse  beat  more  than  ninety  times,  and 
in  two  of  these  it  rose  beyond  one  hundred  ;  in  two  others,  only 
seventy  pulsations  could  be  counted ;  and  in  two  others,  from 
seventy  to  eighty.  I  have  not  been  able  to  ascertain  the  pulsa- 
tions of  but  a  small  number  over  the  age  of  one  year,  but  I  have 
almost  always  found  them  more  frequent  than  in  adults. 


ON  THE    DISEASES    OF   INFANTS*  57 

From  the  preceding  details,  it  appears  that  the  pulse  of  a  very 
young  infant  is  often  not  much  more  frequent  than  that  of  an 
adult,  but  that  it  increases  in  frequency  in  proportion  as  the 
child  advances  in  age;  whence  it  follows,  that  it  is  wrong  to  as- 
sert in  a  manner  so  exclusive  and  general  as  is  usually  done,  that 
the  pulse  in  children  is  more  frequent  than  in  adults.  It  appears 
to  me  to  be  clearly  demonstrated  that  this  rule  has  many  excep- 
tions. 

The  pulse  of  new-born  children  has  other  characteristics  than 
those  drawn  from  its  frequency.  It  is  very  often  found  irregular, 
and,  as  it  were,  jerking,  from  the  sudden  changes  experienced  at 
the  period  of  birth,  by  the  circulatory  apparatus,  and  the  irregu- 
larity with  which  these  organs  at  first  execute  their  functions. 
It  is  often  small,  thread-like,  and  easily  compressed.  I  have  re- 
marked that  it  is  not  always  isochronous  with  the  beats  of  the 
heart ;  or  at  least,  on  applying  one  hand  to  the  heart  and  the 
other  to  the  arm,  a  movement  of  the  heart  not  responded  to  by  the 
radial  artery  might  be  distinguished,  or  that  the  latter  followed 
but  slowly. 

In  treating  of  the  particular  diseases  of  children,  I  will  point 
out  the  modifications  which  the  pulse  undergoes  ;  but  after  the 
preceding  remarks,  we  can  easily  understand  how  difficult  it 
must  be,  accurately  to  distinguish  these  modifications,  and  to 
draw  from  them  any  useful  inferences  in  symptomatology. 
Happily,  at  this  day  physicians  attach  less  importance  to  the 
scholastic  divisions  which  the  celebrated  Bordeu  thought  so 
necessary  to  the  study  of  the  pulse,  and  that  they  direct  their  at- 
tention more  to  those  signs  which  are  better  calculated  to  expose 
the  seat  and  nature  of  those  alterations,  which,  forming  in  the 
most  remote  of  our  oro^ans,  endans^er  life  itself 


CHAPTER  Till. 

OF    FEEBLENESS    OF    BIRTH. 

Children  present  sometimes  at  their  birth  an  intermediate 

state  between  sickness  and  health  ;  this  is  what  I  term  the  feeble- 

8 


58  ON   THE    DISEASES   OP   INFANTS. 

ness  of  birth.  The  expression  is  often  very  vaguely  employed, 
and  the  apparent  feebleness  is  not  always  the  result  of  imperfect 
development  of  the  foetus,  as  is  observed  in  premature  children, 
but  of  more  or  less  important  alteration  in  some  organ  essential  to 
life,  an  alteration  commencing  while  the  child  was  within  the 
womb. 

I  propose  to  show  in  the  course  of  the  work,  the  truth  of  this 
remark,  and  will  endeavor  here  to  fix  the  proper  idea  which 
should  be  attached  to  the  term,  feebleness  of  birth. 

If  the  external  condition  of  new-born  children  be  examined, 
those  will  be  considered  as  feeble  where  the  trunk  and  limbs  are 
thin,  where  respiration  is  difficult,  and  where  the  cries  are  scarce- 
ly heard,  and  who,  being  unable  to  retain  the  drinks,  or  milk,  ap- 
pear always  about  to  expire.  If  we  trace  this  state  of  the  system 
to  its  proper  source,  we  will  find  the  causes  to  be  very  variable, 
and  referable  to  various  kinds  of  lesions. 

I  will  not  in  this  place  give  a  detailed  history  of  all  the  cases 
in  which  I  have  found  lesions  of  a  serious  character  in  those 
children  that  were  born  in  the  state  just  mentioned,  but  will  only 
make  a  recapitulation,  reserving  a  description  of  these  diseases 
to  a  more  suitable  place  for  their  consideration,  according  to  the 
plan  of  this  work. 

In  the  first  place,  I  will  remark,  that  it  is  necessary  to  distin- 
guish the  feebleness  of  birth  from  the  pulmonary  or  cerebral 
congestions  often  produced  by  some  cause  during  labor.  These 
accidents  are  recent,  and  the  child  affected  exhibits,  with  the 
exception  of  drowsiness  or  syncope,  all  the  natural  vigor  of  health. 

But  it  is  not  the.  same  with  those  debilitated  children  whose 
limbs  are,  as  it  were,  almost  deprived  of  flesh,  and  whose  bodies 
are  covered  with  wrinkles,  and  their  eyes  sunk,  and  their  gen- 
eral appearance  of  the  most  frightful  description. 

I  found  in  eighteen  children,  born  at  the  full  time,  and  in  a 
complete  state  of  debility  and  emaciation,  a  very  intense  inflam- 
mation of  the  gastro-intestinal  apparatus.  In  six  others,  pneu- 
monia had  evidently  existed;  in  two,  a  peritoneal  inflammation, 
characterized  by  adhesions  already  quite  firm,  and  by  the  efliision 
of  a  yellowish  fluid ;  and  in  one  there  were  signs  of  chronic 
pleurisy.  These  facts  will  be  subsequently  referred  to,  with  all 
the  circumstances  which  render  them  interestinsf. 


ON   THE    DISEASES    OF    INFANTS.  59 

It  is,  nevertheless,  far  from  being  true,  that  all  children  born 
with  important  changes  in  some  one  of  their  organs,  exhibit  the 
emaciation  and  feebleness  of  which  we  are  speaking ;  the  contra- 
ry will  hereafter  be  seen  to  be  the  case  ;  and  I  will  also  here  state, 
in  anticipation,  that  a  very  serious  disorganization  of  the  cerebro- 
spinal apparatus  often  exists  while  the  form  and  symmetry  of 
the  child  are  not  in  the  least  affected,  but  present  the  usual  signs 
of  healthy  development.  We  also  not  unfrequently  see  chil- 
dren quite  robust  at  birth,  if  we  may  judge  from  their  good  con- 
dition and  the  proper  conformation  of  their  limbs,  expire  some 
hours  or  days  after  birth,  and  presenting,  on  the  examination  of 
the  body,  a  sanguineous  congestion  of  the  principal  organs,  such 
as  the  brain,  lungs,  or  intestinal  canal,  with  an  effusion  of  blood 
in  the  cavities  of  these  parts. 

On  the  other  hand,  all  children  born  emaciated  and  feeble,  are 
not  necessarily  affected  with  serious  lesions,  and  upon  a  post 
mortem  examination  they  often  exhibit  none ;  of  which  the 
following  is  an  example. 

CASE  I. — Marie  Loisel  was  brought  on  the  5th  of  August,  1826, 
immediately  after  birth,  to  the  Hospice  des  Enfans  Trouves.  She 
measured  thirteen  inches  and  a  half  in  length,  the  superior  and  infe- 
rior extremities  were  extremely  small,  the  face  was  pinched  and  very 
red,  the  integuments  of  the  ordinary  color,  the  movements  but 
feeble,  and  the  cry,  although  perfect,  was  scarcely  audible.  The 
temperature  of  the  surface  was  natural.  She  drank  without  vomiting, 
but  refused  the  breast.  In  the  evening,  she  passed  a  considerable 
quantity  of  meconium.  She  continued  for  some  days  in  this  state, 
and  died  on  the  morning  of  the  10th  day,  presenting  no  symptoms 
but  those  of  extreme  feebleness. 

On  examining  the  body  twenty-four  hours  after  death,  the  mouth 
was  found  healthy,  the  oesophagus  injected,  particularly  at  the  lower 
part,  the  internal  surface  of  which  was  lined  with  thick  mucus,  the 
liver  small,  and  the  lungs  crepitant,  except  at  the  posterior  part, 
wherethey  were  engorged.  The  ductus  arteriosus  and  the  foramen 
ovale  were  quite  open.  The  brain  was  a  little  softened,  and  of  a 
yellowish  tint ;  the  lateral  ventricles  contained  a  red  serous  effusion. 
In  the  cellular  tissue  of  the  limbs  there  was  found  a  yellowish  and 
limpid  serum. 


60  ON   THE    DISEASES   OF    INFANTS. 

It  is  evident  that  death  in  this  child  was  caused  by  the  state 
of  universal  feebleness  existing  from  birth ;  this  congestion  of 
the  intestinal  canal,  the  serous  effusion  in  the  ventricles  of  the 
brain,  and  infiltration  of  the  limbs,  denote,  I  should  think,  a  pas- 
sive and  almost  an  inanimate  condition  of  the  principal  organs, 
and  especially  of  those  appertaining  to  the  circulation.  We  shall 
hereafter  present  other  analogous  facts  ;  it  is  however  admitted, 
that  these  conditions  are  rare  without  the  existence  of  some  other 
morbid  causa  than  that  of  general  debility  of  a  new-born  child. 
Children  often  fall  into  a  state  of  marasmus  after  birth,  which 
M.  Gardien  has  described  under  the  title  of  feebleness  of  new- 
born children.  It  will  be  seen  hereafter,  that  this  progressive 
feebleness  is  often  produced  by  chronic  phlegmasise  of  the  di- 
gestive organs,  in  which  the  employment  of  stimulants  and 
tonics,  as  is  recommended  by  M.  Gardien  to  restore  the  sinking 
powers  of  the  child,  is  contra  indicated.  In  the  course  of  this 
work  numerous  proofs  of  the  positions  now  advanced  will  be 
given. 

From  all  these  considerations,  it  will  appear — 1st,  That  in 
every  instance  in  which  an  infant  is  born  feeble,  thin,  and  pos- 
sessing but  little  vitality,  these  symptoms  should  not  be  attributed 
to  a  feeble  development  of  its  organization.  2dly,  That  a  variety 
of  different  lesions  may  be  the  cause.  3dly,*  That  before  ad- 
ministering tonics  and  stimulants,  we  ought  to  search  for  the 
true  cause  of  the  existing  debility ;  an  examination  of  which 
can  be  made,  if  the  nature,  progress,  and  symptoms  of  the  dis- 
eases of  children  at  the  breast  be  properly  studied. 


PART    II. 

DISEASES  OF  INFANTS. 

During  the  period  in  which  the  embryo  undergoes  the  various 
changes  necessary  to  its  complete  development,  two  kinds  of 
causes  may  operate  to  produce  alterations  in  the  form  or  texture 
of  its  parts.  The  first  arises  from  an  imperfect  development 
of  the  viscera.  The  other,  difficult  to  explain,  but  easily  under- 
stood by  its  effects,  produces  alterations  in  the  texture  of  the 
organs  analogous  to  those  occurring  during  life,  which  produce 
our  diseases. 

The  first  order  of  causes  has  been  studied  latterly  with  great 
care  by  the  most  celebrated  anatomists,  to  whose  labors  we  are 
at  the  present  time  indebted  for  the  satisfactory  explanations  of 
the  nature  of  some  monstrosities. 

As  to  the  other  alterations,  it  appears  to  me  that  they  have  not, 
as  yet,  sufficiently  attracted  the  attention  of  physicians,  although 
they  are  doubtless  of  great  importance  in  the  study  of  infantile 
diseases. 

If,  therefore,  it  is  our  wish  to  investigate  the  affections  of  the 
different  organs  of  children,  it  will  be  necessary  to  point  out  the 
principal  congenital  m.alformations.  together  with  the  alterations 
of  texture  which  each  organ  undergoes  during  intra-uterine  life. 
It  is  this  which  I  now  propose  to  do ;  and  also  to  describe  the 
symptoms  by  which,  at  the  birth,  a  correct  diagnosis  of  the  vari- 
ous alterations  may  be  made ;  and  considering,  in  their  course, 
those  diseases  which  are  developed  after  birth.  The  therapeutic 
agents  necessary  for  their  relief  will  conclude  the  history  of  each 
disease. 

I  shall  study  successively  the  affections  of  the  skin,  cellular 
tissue,  digestive,  respiratory,  circulatory,  cerebro-spinal  appara- 
tuses ;  and  lastly,  the  locomotive  system  and  that  of  generation. 


62  ON"   THE    DISEASES    OF    INFANTS. 

As  above  stated,  congenital  changes  of  the  organs  are  divided 
into  two  kinds :  malformations  and  alterations  of  texture.  By 
congenital  malformations  I  understand — 1st,  Those  which  result 
from  the  progress  of  development  having  been  arrested,  so  that 
the  affected  organ  exhibits  nothing  more  than  the  rudiments  of 
its  primitive  formation  ;  2dly,  Those  which  occur  from  a  species 
of  hypertrophy  of  the  organ  ;  and  3dly,  Those  presentmg  a  simple 
deformity  in  the  diameter  or  continuity  of  the  different  parts  of  the 
body.*  By  alterations  of  texture,  I  mean  those  changes  which 
a  morbid  cause  produces  in  the  color  and  texture  of  the  organ, 
without  its  general  form  being  apparently  changed.  I  will  begin 
with  the  consideration  of  the  diseases  of  the  external  integu- 
ments, because  they  are  the  first  that  are  submitted  to  the  inspec- 
tion of  the  physician. 


CHAPTER    I. 

OF  THE  DISEASES  OF  THE  SKIN. 
Section  I. 

MALFORMATIONS  AND  CONGENITAL  DISEASES  OF  THE  SKIN. 

The  embryo  until  the  middle  of  the  second  month  has  no 
distinct  skin  ;  but  about  that  period,  according  to  Autenrieth, 
the  epidermis  begins  to  show  itself  Until  about  four  months 
and  a  half,  the  skin  is  thin,  colorless,  and  transparent.  It  then 
assumes  a  rosy  hue  until  about  the  eighth  month  ;  at  this  time  it 
becomes  paler,  except  in  the  folds.  About  the  middle  of  preg- 
nancy the  sebaceous  follicles  appear,  first  in  the  head,  and  after- 
wards in  the  other  parts  of  the  body  ;  at  seven  months  the  seba- 
ceous or  caseous  envelope  appears,  and  at  birth  the  skin  is  co- 
vered with  it,  and  is  of  a  rosy  white.f 

*  Hlstoire  gene  rale  tt  particuliere  des  anomalies  de  V organisation  chez  Phommc 
et  les  animaux  :  by  Isidore  Geoflfroy-Saint-Hilaire.   Paris,  1832. 
t  Beclard,  Anat.  G^n.  p.  291. 


ON    THE    DISEASES   OF    INFANTS.  63 

§  I.  Absence  of  the  skin — The  skin  may  be  deficient 
in  one  or  several  parts  of  the  body,  but  this  state  almost  always 
coexists  with  the  absence  of  the  parts  beneath.  Thus,  the  skin 
covering  the  abdomen,  thorax,  or  head,  is  defiicient  when  the  os- 
seous or  muscular  parts  of  these  cavities  are  absent.  When  a 
large  portion  of  the  skin  is  deficient  in  a  foetus,  the  borders  of  the 
defective  part  are  red,  a  little  hardened,  and  quite  adherent  to  the 
subjacent  parts.  In  short,  they  exhibit  all  the  appearance  of  a 
true  disorganization. 

The  destruction  of  the  skin  may  be  produced  in  the  embryo 
in  two  difiTerent  ways  during  its  confinement  in  the  uterus.  We 
often  see  rachitis  existina:  in  the  new-born  child  without  the  skin 
being  disorganized ;  but  the  progress  of  the  tumor  more  fre- 
quently produces  a  thinning  of  the  skin  which  covers  it,  followed 
by  ulceration  and  rupture.  Now,  that  which  is  observed  after 
birth  may  exist  in  the  uterus ;  and  without  doubt  it  is  in  this 
manner  that  the  thinning  or  ulceration  of  the  skin,  which  covers 
the  tumor  of  spina  bifida  in  some  children  at  the  period  of  birth, 
occurs  either  in  the  sacrum  or  spine.  This  destruction  is  evi- 
dently the  result  of  the  fluid  accumulated  in  the  tumor,  causing 
distention  and  irritation  in  the  part,  augmented  by  the  frictions  to 
which  a  projecting  part  is  exposed. 

Again,  the  disorganization  of  the  integuments  of  the  foetus 
may  be  produced  in  the  following  manner  :  the  uterus  may  con- 
tain in  its  cavity  some  morbid  production  which  alters  its  form 
and  capacity,  and  that  part  of  the  integuments  of  the  foetus 
which  is  in  contact  with  the  projecting  part  of  the  uterus  may 
become  thin  and  even  disorganized,  and  the  child  at  birth  exhibit 
evident  traces  of  this  compression  and  disorganization  of  the  skin. 

I  found  in  a  child  recently  born,  the  history  of  whose  case  is 
reported  in  the  chapter  on  hernia  of  the  cerebrum,  a  destruction 
of  the  skin  over  the  left  parietal  bone.  It  was  replaced  by  a 
vermilion-colored  cicatrix,  depressed  and  smooth,  an  inch  and 
a  half  in  length,  and  four  lines  in  breadth.  The  parietal  bone, 
which  was  depressed  in  this  place,  exhibited  also  an  oblong  open- 
ing scarcely  an  inch  long,  the  circumference  of  which  was  irregu- 
larly round. 

From  the  deformity  of  the  head,  the  depression  in  one  part  of 
the  cranium,   and  the  complete  destruction  of  the  scalp,  to- 


64  ON  THE    DISEASES   OF   INFANTS. 

gether  with  the  wearing  away  of  the  parietal  bones  at  the 
place  of  depression,  I  inferred  that  there  had  existed  in  the 
womb  a  projection,  such  as  a  polypus  for  instance,  which, 
coming  in  contact  with  the  portion  of  the  cranium  just  described, 
destroyed  its  integuments  ;  or  that  a  malformation  of  the  pelvis 
had  restrained  the  development  of  the  uterus.  It  is  to  be  re- 
gretted that  the  form  of  the  womb  in  the  mother  of  this  child 
could  not  have  been  ascertained,  and  that  it  could  not  be  known 
whether  during  her  pregnancy  she  had  received  a  blow  upon 
the  abdomen.  Be  this  as  it  may,  these  conjectures  are  supported 
by  a  fact  sufficiently  evident  to  render  them  at  least  probable. 
On  this  subject,  Hippocrates  has  expressed  an  opinion  in  his 
treatise  on  generation  which  is  worthy  of  notice.  He  not  only 
thinks  that  if  during  pregnancy  the  mother  receives  a  blow  on 
the  abdomen  the  infant  will  be  injured  in  a  part  corresponding 
to  the  place  on  which  the  blow  had  been  received,  but  adds  be- 
sides : — "  Quin  et  alia  hujusce  modi  causa  mutilantur  pueri ; 
quum  uteri  locus  qua  parte  mutilati  sunt,  angustior  fuerit ;  ne- 
cesse  est  corpus  quod  angusto  in  loco  movetur,  illic  mutilum 
fieri." — [De  Genit^trd,  cap.  vi.)  The  preceding  observation 
corresponds  remarkably  with  this  idea  of  the  father  of  medecine. 
The  case  published  by  Lesage  (Bulletin  de  laFac.  1805)  is  like- 
wise an  instance  in  point ;  that  of  a  fostus  bearing  on  the  fore- 
head the  traces  of  a  lesion  which  appeared  to  have  been  pro- 
duced by  a  blow  given  to  the  mother  on  the  abdomen.  Professor 
Chaussier  also  has  observed  some  analogous  facts.* 

Therefore,  the  skin  of  a  foetus  in  the  uterus  may  be  destroyed 
to  a  greater  or  less  extent,  whether  this  effect  be  produced  by  a 
tumor  developed  on  the  surface  of  the  body  of  the  child,  thus 
exposing  the  skin  to  a  considerable  distension,  producing  thereby 
a  thinning  and  ulceration  ;  or  whether  there  had  existed  in  the 
womb  a  hardened  and  projecting  part,  against  which,  notwith- 
standing the  protecting  influence  of  the  liquor  amnii,  a  portion 
of  the  foetus  had  pressed.f 

*  See  also  an  instance  related  by  M.  Geoffroy-Saint-Hilaire,  in  which  a  child  had 
been  injured  in  the  third  month,  and  became  in  consequence  a  monster.  {Mem.  de  la 
(Soc.  medicale  de  V emulation.     Tome  ix.     Paris,  1826.)     See  Appendix,  page  550. 

t  There  may  exist  also  another  cause  of  inflanmaation  and  ulceration  of  the  skin 
of  a  foetus  before  birth.     It  is  well  known  that  the  absence  of  contact  of  the  atmo- 


ON   THE    DISEASES    OF    INFANTS.  65 

When  a  child  exhibits  at  birth  this  want  of  integuments,  it 
will  be  necessary  to  apply  a  bandage  capable  of  protecting  and 
sustaining  the  organs  deprived  of  their  natural  coverings,  and  at 
the  same  time  promoting  the  cicatrization  of  the  ulcerated  part. 

§  11.  Cutaneous  excrescences. — The  skin  may  exhibit 
malformations  by  superfluous  growth.  Congenital  cutaneous 
excrescences  almost  always  result  from  a  fold  or  elongation  of  the 
skin,  developed  in  various  parts  of  the  body.  These  cutaneous 
prolongations  may  be  observed  on  the  face,  body,  or  limbs.  They 
are  more  commonly  seen  on  the  face,  hands,  and  feet ;  and  are 
sometimes  of  so  great  a  length  as  to  produce  a  true  deformity. 
Meckel  remarks  that  they  are  generally  accompanied  with  a 
defective  development  in  the  tegumentary  membrane  at  other 
points.     I  saw  at  the  Hospice  des  Enfans  Trouves.  a  female  in- 

sphere  on  the  skin,  contributes  in  certain  cases  to  pro  Juce  a  local  transformation  of  the 
skin,  imparting  to  it  the  peculiar  properties  of  a  mucous  membrane.  This  is  observed 
in  the  deep  folds  produced  by  the  flexion  of  the  limbs  of  fat  children,  and  it  also  fol- 
lows long  standing  muscular  contractions.  Hebreard  has  long  since  cited  facts  of 
this  kind  to  demonstrate  the  analogy  between  the  skin  and  mucous  membrane.  (Mem. 
de  la  Soc.  Med.  d^ emulation.  Tome  viii.)  There  is  no  doubt  that  the  liquor  amnii  has 
an  influence  on  the  surface  of  the  body  of  a  foetus  in  the  uterus,  analogous  to  that  of 
the  air  upon  the  body  of  a  child  after  birth,  as  is  evident  when,  from  the  peculiar  posi- 
tion of  the  limbs  of  the  foetus,  they  are  withdrawn  from  the  action  of  the  fluid.  The 
skin  at  first  softens,  then  inflames,  and  finally  ulcerates.  The  following  case  reported 
by  Dr.  OlUvier,  of  Angers,  presents  a  remarkable  instance  of  an  aff'ection  of  the  skin 
from  this  cause. 

On  the  24th  of  April,  1828,  a  female  infant  two  days  old,  was  brought  to  him, 
exhibiting  a  rare  variety  of  club  foot ;  the  two  feet  were  turned  over  on  the  legs, 
so  that  the  dorsal  surface  of  each  foot  was  in  direct  contact  with  the  anterior  part 
of  the  leg.  On  the  left  side,  above  the  external  malleolus,  in  the  folds  resulting  from 
this  forced  flexion  of  the  foot  on  the  leg,  there  existed  two  ulcerations  in  the  skin,  of 
a  grayish  color  at  the  bottom,  very  red  and  bloody  at  the  borders,  having  the  appear- 
ance of  a  recent  burn  of  the  second  degree.  The  right  foot  at  its  internal  part,  and 
on  its  entire  dorsal  surface,  together  with  the  lower  third  of  the  anterior  face  of  the 
corresponding  hmb,  exhibited  a  large  eschar  of  a  grayish  yellow,  surrounded  by  an 
inflammatory,  red,  and  bloody  circle.  This  ulceration  also  resembled  a  recent  burn. 
The  accoucheur  having  noticed  this  singular  alteration  in  the  skin,  at  the  time  of  the 
birth  of  the  child,  applied  over  it  compresses  wetted  with  a  decoction  of  marshmallows, 
without  its  producing  any  alteration  in  the  ulcer. 

Dr.  OUivicr,  after  ascertaining  that  a  moderate  degree  of  extension  easily  restored 
the  two  feet  to  their  natural  situation,  advised  the  application  of  an  extensory  bandage 
to  oppose  the  unnatural  flexion,  at  the  same  time  applying  Goulard's  cerate  to  the  ul- 
cerated surfaces.  This  treatment,  pursued  with  care,  was  followed  by  a  complete 
cicatrization  of  the  two  ulcers,  and  shortly  by  a  restoration  of  the  feet  to  their  proper 
position. 

9  . 


66  ON  THE   DISEASES  OP   INFANTS. 

fant,  who  had  upon  each  cheek  a  cutaneous  excrescence  about 
half  an  inch  long,  and  of  the  thickness  of  a  crow-quill.  There 
were  also  two  others  on  the  same  child,  of  the  same  thickness, 
but  much  less  prominent,  before  each  ear.  The  concha  of  the 
left  ear  scarcely  existed,  and  there  was  a  complete  closure  of  its 
opening.  As  to  other  parts,  the  child  was  perfect  in  every  re- 
spect, and  enjoyed  good  health  ;  after  a  few  days,  she  returned  to 
her  parents,  who  had  only  temporarily  placed  her  in  the  hospital. 

These  cutaneous  excrescences  ought  to  be  removed  within  a 
few  days  after  birth,  as  the  cicatrix  resulting  from  their  excision 
will  be  less  apparent,  and  will  after  a  while  be  gradually  effaced. 
The  best  method  of  removing  them,  I  think,  is  by  ligature,  which 
should  be  applied  at  their  point  of  insertion. 

We  must  not  confound  these  excrescences  with  tumors  arising 
from  fungus  haematodes,  a  disease  which  we  shall  consider  here- 
after. 

Authors  have  described  excrescences  formed  on  the  skin,  of  a 
horny  nature.  This  production  has  often  been  observed  in  adults 
and  old  people  ;  but  it  is,  T  believe,  extremely  rare  to  meet  with 
them  among  children,  and  particularly  in  new-born  infants.  I 
therefore  point  out  this  alteration  of  the  integuments,  as  one  of 
possible  occurrence.  These  pathological  productions  should,  in 
all  cases,  be  promptly  removed,  together  with  a  portion  of  the 
skin  to  which  they  are  attached. 

Children  have  been  sometimes  seen  covered  with  hair.  Haller 
observes  that  there  were  such  cases,  which  induced  ignorant 
people  to  regard  them  as  bears  or  goats.* 

We  can  easily  account  for  this  anomaly.  The  skin  about  the 
middle  of  the  intra-uterine  life  is  covered  with  a  quantity  of  hair, 
which,  for  the  most  part,  falls  off  sometime  before  birth.  These 
are  the  hairs  which  are  found  in  the  water  of  the  amnios,  and 
sometimes  in  the  meconium  of  the  foetus.  But  if  it  happens  that 
this  hair,  instead  of  falling  off,  undergoes  a  considerable  de- 
velopment and  remains  on  the  skin  after  birth,  the  child  exhibits 
the  appearance  of  which  Haller  speaks ;  the  body,  face,  and 
limbs  are  covered  with  it, but  instead  of  presenting  an  inexplicable 
phenomenon,  it  is  simply  an  amplification  of  a  normal  develop- 

♦  Opera  Minora^  de  monstris,  liber  i.  Valsnieri  has  also  reported  examples  of  the 
same  kind. 


ON   THE    DISEASES    OP    INFANTS.  67 

merit — an  irregularity  of  the  general  laws  which  govern  the 
growth  of  the  embryo,  and  one  of  the  number  of  the  series  of 
aberrations  which  are  constantly  observed  while  studying  human 
organization. 

We  ought  in  this  case  to  avoid  the  use  of  any  topical  application 
to  the  skin,  for  the  purpose  of  destroying  these  hairs,  as  it  is 
thereby  exposed  to  irritation,  and  the  health  of  the  child  endan- 
gered. They  will  fall  off  altogether,  or  in  part,  without  any 
remedy,  and  the  surface  of  the  body  will  soon  lose  the  repulsive 
aspect  produced  by  this  abnormal  growth. 

The  hair  of  the  head  may  be  more  or  less  abundant,  but  its 
development  presents  nothing  worthy  of  remark. 

Hair  is  sometimes  to  be  observed  in  deep-seated  or  subcutane- 
ous tumors,  a  condition  very  difficult  to  account  for,  and  which 
also  exists  as  frequently  in  adults  as  in  infants. 

The  nails  vary  but  little  with  respect  to  their  structure  ;  neither 
do  they  offer  any  thing  remarkable  as  to  the  place  of  their  growth. 
The  only  thing  worthy  of  notice,  is  their  presence  in  the  midst 
of  steatomatous  matter  enclosed  in  cysts. 

Accidental  horny  productions  are  more  often  to  be  seen  in  old 
people ;  they  are  very  rare  in  infants,  and  it  is  only  to  persons 
advanced  in  ajge,  that  the  following  passage  from  Haller  is  ap- 
plicable : — 

'•  Cornua  etiam  hue  referas  alieno  loco  in  animalibus  femellis 
reperta  quorum  soli  mares  ex  naturae  ordine  cornuti  sunt ;  aut 
in  aliis  animalius  speciebus  ne  mares  quidem  cornua  gestant  ut 
in  lepore,  catello,  sue,  et  demum  in  hoTnmihus  eflloruerunt."* 

If  horny  excrescences  be  observed  in  a  new-born  child,  they 
should  immediately  be  removed,  at  least  if  the  actual  condition 
of  the  child  should  not  forbid  the  early  operation. 

§  III.  Alterations  of  color. — Alterations  in  the  color  of 
the  integuments  are  not  less  remarkable  than  their  malformations. 
Haller  reports  examples  of  black  children  having  been  born  of 
white  parents,  and  white  children  of  negro  parents.  He  also 
says  that  there  have  been  seen  spotted  infants.  Formerly  these 
anomalies  were  considered  as  the  effect  of  the  capricious  sport- 
ings  of  nature,  by  which  she  would  sometimes  disfigure  her 
fair  productions  ;  but  at  the  present  day  we  ought  rather  to  seek 

*  Demonstris,  lib.  i.,  hist.  cap.  iii.,  p.  5. 


68  ON    THE    DISEASES    OF    INFANTS. 

for  their  causes,  which  our  knowledge  of  the  growth  of  the  fostus 
enables  us  in  some  measure  to  accomplish. 

The  skin  does  not  at  first  exhibit  its  different  component  parts. 
A  simple,  thin,  and  transparent  pellicle,  it  may  be  said  to  be 
primarily  a  continuation  of  the  amniotic  membrane  with  which 
the  umbilical  cord  is  covered ;  the  line  of  demarcation  at  the 
point  of  the  insertion  of  the  cord  cannot  be  distinguished.  It 
remains  thin  and  colorless  for  four  or  five  months,  when  it  greatly 
augments  in  consistence  and  thickness ;  blood  abounds  in  the 
rete  mucosum^  and  the  skin  of  the  foetus  assumes  a  clear,  rosy 
hue.  Thus  it  is  to  the  afflux  of  blood  to  the  skin  that  this  part 
ows  its  color  ;  and  to  the  various  modifications  which  the  blood 
undergoes,  must  the  coloring  of  the  skin  be  attributed,  as  it  ap- 
pears in  the  shades  of  hue  in  the  different  races  of  men. 

But  if  from  some  cause  which  we  may  not  be  fully  able  to 
explain,  it  should  happen  that  the  blood  in  circulating  towards 
the  integuments  undergoes  a  change  in  its  composition  or  in  its 
course,  then  these  will  account  for  the  variety  of  color  and  al- 
tered appearance  of  the  integuments  observed  by  anatomists  in 
certain  infants.  In  order  to  examine  this  proposition,  let  us  con- 
sider, in  the  first  place,  what  are  the  alterations  in  color  which  the 
blood  in  general  undergoes  in  the  tissues. 

1st.  It  sometimes  happens  that  the  blood  is  suddenly  inter- 
rupted in  its  course,  and  flowing  from  its  natural  passages,  ex- 
travasates,  and  diffuses  itself  beneath  the  surface  and  in  various 
other  parts  of  the  body,  as  has  been  observed  by  Whenloff,  Stall, 
and  a  number  of  other  authors,  constituting  what  is  called  pete- 
chias or  spotted  diseases. 

2dly.  The  blood,  either  by  yielding  to  the  force  of  gravity,  or  in 
consequence  of  being  concentrated  by  the  stimulus  of  inflamma- 
tion, accumulates  in  a  particular  part,  and  acquires  a  violet, 
brownish,  and  lastly  a  black  color.  This  is  to  be  observed  on 
the  surface  of  the  lungs  and  in  the  intestinal  canal,  and  to  this 
cause  may  also  be  assigned  the  black  lines  and  spots  seen  on  the 
surface  of  mucous  membranes. 

3dly.  The  blood  may  not  furnish  the  coloring  principle  to  the 
skin,  either  because  this  principle  is  wanting  in  some  individuals, 
or  because  the  fine  net-work  of  the  skin  is  not  in  a  condition  to 
receive  it ;  the  integuments  and  the  hair,  for  these  reasons,  will 


ON    THE    DISEASES    OP    INFANTS. 


69 


maintain  the  same  destitution  of  color  which  they  possessed  at 
an  early  period  of  the  foetal  life,  presenting  the  appearances  which 
are  seen  in  albinos.* 

From  these  considerations,  it  is  possible  that  children  who  are 
said  to  have  been  born  spotted,  black,  or  white,  are  so  during 
their  intra-uterine  life ;  that  the  blood  that  is  extravasated  to 
form-  the  spots  or  petechias  has  not  imparted  to  the  integuments 
its  usual  coloring  material,  which  produces  albinos,  or  finally, 
has  experienced  a  change  in  color,  causing  the  brown  or  black 
appearance  of  the  integuments,  as  has  recently  been  observed 
in  an  adult  at  "  la  Charite"  hospital. 

However,  there  should  not  be  much  importance  attached  to 
these  peculiar  colors  of  certain  infants  ;  yet  we  ought  to  examine 
them  with  some  care,  before  pronouncing  them  to  be  congenital. 
Doctor  Launay,  chief  assistant  surgeon  to  the  military  school  at 
Saint  Cyr,  sent  me  in  the  year  1826,  an  embryo,  about  two 
months  old,  the  entire  surface  of  the  body  of  which  was  black. 
He  obtained  it  from  a  person  ignorant  of  anatomy,  who  had 
preserved  it  for  twenty  years  in  alcohol,  under  the  idea  that  it 
was  a  negro.  In  order  to  give  more  weight  to  this  notion,  on 
which  account  alone  it  was  interesting  to  him,  he  said  that  the 
embryo  had,  at  a  former  period,  been  brought  from  foreign  parts. 

But  considering,  in  the  first  place,  that  the  offspring  of  negroes 
are  not  born  black,  and  being  desirous  of  aiding  my  judgment  in 
this  case  by  anatomy,  I  dissected  with  great  care  the  different 
organs  of  this  embryo,  all  of  which  I  found  black,  like  the  sur- 
face, and  in  an  evident  state  of  decomposition-  Thus,  then,  the 
black  coloring  of  this  subject  w^as  owing  to  a  true  decomposition, 
the  progress  of  which  had  been  arrested  or  suspended  by  its  im- 
mersion in  alcohol,  after  this  change  of  color  had  commenced. 
The  imaginary  history  of  this  fcetus  might  easily  have  been 
credited,  without  an  attentive  examination  of  its  actual  condition. 
§  rV.  Spots,  or  ncevi  materni. — Spots  on  the  skin,  form  a^ 
transition  between  the  malformations  and  the  inflammatory  con- 
dition of  the  integuments. 

The  origin  and  cause  of  these  spots  are  very  obscure.      For 

♦  Reflexions  sur  la  leucopathie,  consideree  comme  leresulat  (Vun retard de develop' 
pement :  by  Doct.  Mansfelt,  of  Brunswick.  Journ.  Complementaire  du  Dictionairt 
des sciences  medicate.     Tom,  25.    p.  43.     Annee  1826. 


70  ON    THE    DISEASES    OP    INFANTS. 

a  long  time,  the  spots  of  birth  have  been  considered  as  the  ef- 
fect of  the  imagination  of  the  mother,  who  had,  during  her  preg- 
nancy, been  alarmed  at  the  sight  of  an  animal,  or  whose  mind 
had  been  affected  with  some  whimsical  desire.  According:  to 
this  idea,  physicians  have  designated  them  by  the  fanciful  names 
oinoevus  mater nus^muttermahl^  mother  spots,  of  the  inaccuracy 
and  inutility  of  which,  we  are  fully  sensible  at  the  present  day. 

They  are  usually  marks  of  varying  sizes,  irregular  in  form, 
and  more  or  less  projecting  ;  appearing  in  every  part  of  the  in- 
teguments, and  generally  of  a  clouded  yellow,  brown,  rose,  red, 
livid,  blue,  or  black,  corresponding  in  this  respect  with  the  ap- 
pearances often  seen  either  on  the  surface  of  the  body,  or  in  deep 
seated  organs  which  have  become  the  seat  of  pathological  altera- 
tions. 

The  cause  of  these  spots  we  might,  therefore,  suppose  to  be  an 
alteration  in  the  cutaneous  pigment,  which,  as  has  been  demon- 
strated by  Blainville,  is  immediately  dependent  on  the  capillary 
circulation.  They  are  then  the  effect  of  disease  in  the  corpus 
mucosum,  in  which  the  capillary  vessels  deposit  the  pigment,  or 
in  the  net- work  of  the  vessels  themselves ;  hence  the  distinction 
established  by  the  researches  of  Callisen,  Bateman,  Abernethy, 
John  Bell,  and  Wardrop,  between  the  pigmentary  and  vascular 
spots;  a  distinction  maintained  also  by  Rozen,  in  his  excellent 
treatise  on  diseases  of  the  skin. 

If  the  congenital  spots  are  the  result  only  of  an  alteration  in 
the  cutaneous  pigment,  we  should  never  meet  with  them  on  the 
surface  of  the  body  of  an  embryo  before  the  third  month,  since 
the  pigment  does  not  exist  at  this  period,  and  it  is  not  until 
about  the  middle  of  the  term  of  gestation,  that  the  skin  of  the 
foetus  receives  a  large  supply  of  blood,  and  acquires  any  high  de- 
gree of  organization.  I  have  examined  about  twenty  embryos 
before  their  arrival  at  the  age  just  mentioned,  and  in  none  of 
them  did  I  observe  these  spots  ;  this,  however,  is  not  a  sufficient 
proof  to  support  my  opinion ;  it  will  only  add  to  the  number  of 
facts  of  the  same  kind  already  existing. 

The  skin,  although  composed  of  parts  sufficiently  distinct  to 
enable  the  anatomist  to  study  them  separately,  really  forms  but 
one  organ,  the  different  parts  of  which  have  so  intimate  a  con- 
nexion, that  it  is  easy  to  conceive  how  a  disease  of  one  may 
involve  the  others  :  the  hairs  and  the  bulbs  of  the  skin,  for  iu- 


ON    THE    DISEASES    OP    INFANTS.  71 

Stance,  may  be  inordinately  developed  in  connexion  with  the 
cutaneous  vessels,  producing  brown  and  red  spots,  covered  with 
colored  hair  more  or  less  prominent,  on  the  surface  of  certain 
parts  of  the  body.  It  is  also  possible  that  the  vascular  net-work 
and  papillge  of  the  skin  may  undergo  an  alteration  independently 
of  the  pilous  system  ;  and  spots,  remarkable  for  their  prominence, 
of  a  brown  or  violet  color,  and  sometimes  their  rugous  aspect, 
are  often  seen  without  any  hairs  upon  them.  Finally,  a  simple 
alteration  in  the  natural  color  of  the  pigment  without  apparent 
tumefaction  may  occur,  exhibiting  those  yellow,  red,  violet,  and 
other  colored  spots,  so  common  on  the  face,  trunk,  and  limbs. 
These  last  are  properly  called  spots,  for  those  which  are  prom- 
inent, and  covered  with  hair,  suppose  an  alteration  in  some  oile 
of  the  other  parts  which  constitute  the  skin. 

The  yellow,  brown,  or  red  spots  which  we  have  just  been  con- 
sidering, remain  stationary  after  birth,  denoting  that  there  ^ists 
no  morbid  action  in  them,  nor  any  tendency  to  disorganizafeon ; 
but  they  present  nothing  more  than  a  simple  change  in  the 
cutaneous  pigment,  and  are,  in  reality,  a  peculiar  property  of  the 
skin :  they  may  continue  as  long  as  the  part  itself  remains,  and 
their  removal  by  caustic  or  a  cutting  instrument,  ought  seldom 
to  be  attempted,  as  scars  will  be  left,  much  more  disagreeable  to 
the  sight  than  the  spots  themselves. 

But  these  remarks  are  not  applicable  to  those  red  vascular  tu- 
mors which  exist  on  young  infants.  Sometimes  they  are  of  an 
oval  shape,  and  pediculated,  consisting  of  a  true  erectile  tissue, 
of  a  bright  red  color,  with  a  granulated  surface ;  they  are  on 
this  account  compared  to  cherries,  raspberries,  or  strawberries ; 
comparisons  which  make  a  strong  impression  on  the  minds  of  the 
generality  of  people,  as  they  accord  with  their  preconceived  no- 
tions. At  other  times,  they  are  less  regular  in  their  shape,  and 
are  situated  more  deeply  under  the  skin,  consisting  of  tumors 
with  large  bases,  and  presenting  a  surface  crossed  by  aneuris- 
matic  vessels ;  the  presence  of  which  enables  us  to  ascertain  their 
cause  and  formation.  These  are  the  tumors  described  by  J.  L. 
Petit,  under  the  name  of  varicose  wens,  known  also  by  the  name 
of  sanguineous  fungi,  aneurisms  of  the  small  arteries,  etc."  They 
differ  from  aneurisms  by  anastomosis,  in  the  want  of  communi- 
cation between  the  arteries  and  veins,  and  in  the  absence  of 


72  ON   TFIE   DISEASES    OF    INFANTS. 

pulsation,  and  the  murmur  peculiar  to  these  aneurisms.  In  both 
cases,  the  cutaneoi\s  projections  produced  and  maintained  by 
the  aneurismatic  dilatation  of  the  small  subcutaneous  vessels, 
are  very  much  disposed  to  enlarge  and  ulcerate  after  birth,  ter- 
minating in  fatal  hemorrhages  ;  so  soon,  therefore,  as  the  age  and 
health  of  the  child  will  permit,  their  growth  should  be  checked, 
or  they  ought  to  be  effectually  removed. 

Different  methods  have  been  proposed  to  accomplish  this  ob- 
ject. Abernethy  has  recommended  refrigerants  and  compres- 
sion.* Professor  Boyer  has  removed  a  noevus  on  the  upper  lip 
by  pressure,  continued  seven  hours  a  day  with  the  finger,  using 
at  the  same  time  a  solution  of  alum  ;t  but  Bateman  has  remarked, 
that  compression  is  sometimes  difficult  to  make,  is  painful,  and 
often  inefficacious ;  I  think  it  would  be  well  to  try  it  on  parts 
easily  compressed,  and  to  discontinue  the  pressure  when  any  un- 
favorable symptom  is  produced. 

Fabricius  de  Hilden,  J.  L.  Petit,  and  John  Bell,  recommend 
the  extirpation  of  the  tumor  by  the  knife,  taking  the  precaution 
of  removing  with  it  a  portion  of  the  adjoining  parts.  This 
method  appears  to  me  much  better  than  the  use  of  caustic,  the 
action  of  which  is  sometimes  difficult  to  control ;  it  should  be 
used  after  compression  has  been  tried  and  found  to  be  ineffectual, 
or  when  this  is  impracticable. 

Wardrop,  one  of  the  most  celebrated  surgeons  of  London,  has 
advised  the  tying  of  the  main  artery  supplying  the  tumor,  and 
afterwards  the  extirpation  of  the  diseased  part ;  it  succeeded  per- 
fectly in  his  hands. t  Perhaps,  without  extirpating  the  tumor 
compression  alone,  after  tying  the  artery,  might  be  sufficient  to 
produce  its  absorption. 

Lawrence  published  an  essay  on  this  subject  in  182G,  in  whicti 
he  proposes  to  pass  a  needle,  armed  with  a  double  ligature,  through 
the  base  of  the  tumor  and  tie  it  on  both  sides,  thus  circumscri- 
bing the  base,  which  being  gradually  compressed,  produces  a 
shrinking,  and  finally  a  complete  destruction  of  the  fungous  tu- 
mor.    Several  cases  treated  in  this  manner,  are  reported  by  him.§ 

*  Traite  des  Malad.  Chirurg. 

t  Surgical  Works,  vol.  2. 

t  Med.  Chir.  trans,  v.  9. 

§  30th  vol.  of  the  Medico-  Chirurgical  transactions. 


ON   THE    DISEASES   OF    INFANTS.  73 

None  of  these  methods  of  removal,  however,  need  be  resorted 
to  immediately  after  birth,  for  it  is  possible  that  the  tumor  may 
remain  stationary  until  puberty  ;  but  they  ought  not  to  be  delayed 
after  the  first  symptoms  of  increase,  or  of  disorganization  appear ; 
the  ulterior  progress  of  the  affection  may  hasten  the  death  of  the 
patient,  or  may  render  the  operation  more  difficult  or  dangerous. 

Section  IL 

diseases  of  the  skin  not  inflammatory,  developed 
during  birth,  or  occurring  subseauently  to  this  pe- 
RIOD. 

I  propose  to  treat  under  this  head  of  local  or  general  conges- 
tion, of  petechias,  and  of  some  alterations  of  color. 

§  I.  EccHYMosEs.—These  found  on  different  parts  of  the  body  of 
a  new-born  infant,  are,  as  is  well  known,  generally  the  result  of 
difficult  labor.  They  are  particularly  to  be  remarked  in  those 
parts  which  haA^e  been  strongly  compressed  in  the  straits  of  the 
pelvis :  this  is  the  ordinary  cause  of  the  ecchymosis  of  the  scalp. 
It  may  be  well  to  observe,  however,  that  this  ecchymosis  is  not 
always  the  result  of  pressure  which  the  head  undergoes  in  passing 
the  pelvis.  In  the  month  of  May,  1827,  I  delivered  a  woman  at 
the  "  Maison  Royale  de  Sante"  of  a  fcetus  about  four  or  five 
months  old ;  she  told  me  she  had  experienced  much  pain  for 
about  fifteen  days,  and  for  eight  days  had  lost  so  large  a  quantity 
of  blood  as  to  give  her  reason  to  apprehend  an  abortion.  The 
membranes  of  this  foetus  were  entire  ;  the  clearness  of  the  liquor 
amnii  enabled  me  to  see  the  foBtus,  the  head  of  which  was  down- 
ward and  the  feet  elevated.  On  the  summit  of  the  head  appeared 
a  large  ecchymosis  surrounded  by  a  number  of  small  vessels 
ramifying  beautifully  over  the  scalp. 

This  child  had  no  doubt  been  dead  for  some  days,  and 
from  the  time  of  its  death,  being  entirely  free  in  the  waters,  the 
fluids  had  submitted  to  the  laws  of  gravity  ;  and  this  ecchymosis 
of  the  skin  of  the  cranium  must  be  regarded,  not  as  the  effect  of 
compression,  but  as  the  result  of  the  position  of  this  part  since 
the  death  of  the  embryo. 

It  is  not  always  so ;  for  in  an  infant  born  at  the  full  time,  by 
either  of  the  first  positions,  it  is  evident  that  the  cause  of  the 

10 


74  ON   THE    DISEASES    OF    INFANTS. 

ecchymosis  is  both  the  position  and  the  compression  of  the  ec- 
chymosed  part. 

In  most  cases,  the  resolution  of  these  tumors  is  effected  spon- 
taneously. If,  however,  they  should  be  accompanied  by  much 
tumefaction  of  the  integuments,  the  application  of  topical  dis- 
cutients,  such  as  a  solution  of  the  muriate  of  soda,  acetate  of 
lead,  or  muriate  of  ammonia,  will  hasten  their  removal.  But  it 
is  seldom  necessary  to  have  recourse  to  these  remedies,  for  general- 
ly the  ecchymosis  and  tumefaction  disappear  of  themselves.  I  have 
made  a  number  of  anatomical  examinations  upon  the  condition 
in  which  the  integuments  of  the  cranium  are  found  when  thus 
ecchymosed,  and  upon  the  period  at  which  the  ecchymosis  usually 
disappears.     The  following  are  the  results  of  these  researches. 

§  II.  Tumor  of  the  scalp. — The  tumor  of  the  scalp,  as  Ca- 
puron  remarks,  may  arise  from  two  causes ;  it  is  either  the  result 
of  an  oedema,  a  serous  infiltration,  or  of  the  accumulation  of  blood. 

In  the  former  case  the  tumor  is  never  well  circumscribed  ;  it 
scarcely  rises  in  the  form  of  a  cone,  but  consists  of  a  general  en- 
gorgement of  the  integuments  of  the  cranium.  It  then  quickly 
disappears. 

In  the  latter  case  the  blood  is  infiltrated  either  in  the  cellular 
tissue,  or  in  the  ultimate  vascular  ramifications  ;  blood  flows  from 
all  the  incisions  made  in  the  scalp,  which  is  black  or  mottled.  It 
is  not  uncommon  to  find  drops  of  blood  interspersed  in  the  adipose 
matter  ;  at  other  times  there  exists  an  effusion  of  blood  between 
the  skin  and  pericranium,  produced  by  exhalation,  or  by  a  rupture 
of  the  small  blood  vessels.  The  blood  is  then  very  black  and 
fluid,  and  is  contained  in  a  sort  of  sac  caused  by  the  separation 
of  the  scalp  ;  all  the  surrounding  parts  are  tinctured  with  a  violet 
red,  even  the  bones  partake  of  this  color,  resulting  evidently 
from  the  absorption  of  this  fluid.  I  once  saw  in  a  child,  three 
days  old,  a  sanguineous  effusion  of  this  species  so  extensive  as  to 
produce  an  entire  separation  of  the  skin  of  the  cranium.  This 
child  died  of  pneumonia,  and  so  universal  was  the  effusion  of 
blood  on  the  exterior  of  the  cranium,  as  to  produce  what  may  be 
termed  a  tegumentary  apoplexy.  The  proper  course  of  treat- 
ment in  these  cases,  I  think,  would  be  to  make  a  longitudinal 
incision  at  the  summit  of  these  sanguineous  tumors,  after  discu- 
tient  remedies  have  failed. 


ON    THE    DISEASES    OF    INFANTS.  76 

The  period  of  the  disappearance  of  the  ecchymosis  and  tumors 
of  the  scalp,  is  very  variable.  I  have  known  children  to  re- 
tain the  traces  of  them  at  the  age  of  fifteen  or  twenty  days,  whilst, 
in  the  greatest  number  of  instances,  they  usually  disappear  at 
the  age  of  eight  days.  It  depends  on  the  extent  of  the  ecchymo- 
sis and  the  quantity  of  blood  effused.* 

"We  should  avoid,  as  Capuron  judiciously  remarks,  confound- 
ing these  tumors  with  encephalocele,  as  the  error  might  be  fatal, 
in  mistaking  the  latter  disease  for  a  sanguineous  tumor ;  the 
distinctive  characters  of  the  two  affections  will  be  pointed  out 
when  treating  of  cerebral  hernia. 

Other  ecchymoses  may  often  be  seen  on  various  parts  of  the 
bodies  of  infants  recently  born.  They  are  always  found  on 
parts  that  have  been  rubbed  or  compressed  ;  they  soon  disappear 
like  those  of  the  head,  undergoing  a  change  in  their  color,  to 
violet,  blackish,  or  yellow,  like  ecchymoses  in  adults. 

§  III.  Contusions. — When  the  use  of  the  fillet,  forceps,  lever, 
or  chrochet,  has  been  found  necessary  to  terminate  labor,  the 
child  often  exhibits  contusions  in  different  parts  of  the  body, 
which  demand  the  attention  of  the  physician,  for  they  may  give 
rise  to  erysipelatous  inflammation,  the  progress  and  complica- 
tions of  which,  endanger  the  life  of  the  child.     Happily,  these 

*  I  do  not  here  allude  to  the  sanguineous  effusions  described  in  the  latter  part  of  the 
last  century,  and  also  quite  recently,  under  the  names  of  abscessus  capitis  sanguineus 
neonatorum,  HcBmatoma,  Hcematoma  capitis,  caphalcBmatoma  neonatorum,  Ecchy- 
moma  capitis.  Tumor  cranii  sanguineus,  by  Levret,  Smellie,  J.  F,  Frank,  Pa- 
letta,  Nagcle,  and  other  authors.  In  this  kind  of  tumor,  the  blood  is  not  simply  effused 
beneath  the  skin,  but  rather  between  the  pericranium  and  the  bones  ;  according  to  the 
observation  of  a  number  of  authors,  this  effusion  results  from  the  rupture  of  the  veins 
near  the  junction  with  the  sinuses ;  according  to  others,  it  occurs  in  the  diploe,  and  de- 
pends on  a  primary  alteration  of  the  bone,  which  often  involves  the  destruction  of  its 
external  table.  It  should  be  added,  that  this  kind  of  sanguineous  tumor  does  not  arise 
from  long  and  difficult  labors,  since  all  authors  agree  that  it  is  observed  when  the  pas- 
sage of  the  child  has  been  quick  and  easy, 

Paletta,  Excercitat.  pathol.  Milan,  1820.  Car.  Zeller,  De  cephalcematomate, 
sen  sanguineo  cranii  tumore  recens  natorum.  Hiedleberg,  1822.  Ant.  Herr.  Hal- 
ler,  De  tumore  capitis  sanguineo  neonatorum,  dissert.  Dorpat,  1824.  G.  C.  L. 
Brandau,  Eccymomata  capitis  recent  natorum.  Morbourg,  1824.  G.  Fr.  Hoere,  Dc 
tumore  cranii  recens  natorum  sanguineo,  et  externo,  et  interno.  Berlin,  1824.  This 
author  admits  a  species  of  sanguineous  tumor,  in  which  the  blood  is  between  the  peri- 
cranium and  dura  mater.  J.  D.  Strewe,  De  cephalcematomate,  seu  sanguineo  cranii  til- 
more  externo  recens  natorum.    Giessen,  1828. 


76  ON    THE    DISEASES    OF    INFANTS. 

accidents  are  less  to  be  feared  at  the  present  day,  when  the  obste- 
tric art  is  reduced  almost  to  the  study  and  direction  of  the  pro- 
gress of  a  function,  which,  however  difficult  or  complicated  it 
may  sometimes  be,  is  not  less  natural  than  those  to  which  our 
bodies  are  daily  subjected  during  the  continuance  of  life.  The 
general  congestion  of  the  skin  of  the  fcBtus  being  ordinarily  con- 
nected with  some  affection  of  the  respiratory  apparatus,  I  will 
reserve  the  consideration  of  this  subject  until  the  diseases  of  those 
organs  are  noticed. 

§  IV.  Petechia. — The  hemorrhagic  spotted  disease,  which 
Riviere,*  Werlhof,t  Bateman,  and  other  authors,  have  described 
under  different  names,  and  the  history  of  which  has  been  so  well 
exhibited  under  the  title  of  Hemacelinose,  in  the  work  of  M. 
Rayer,t  are  seen  in  feeble  and  badly  nourished  children,  where 
the  capillary  circulation  is  found,  from  some  cause  difficult  to 
ascertain,  quite  deranged,  and  disordered  in  such  a  manner  as  to 
give  rise  to  effusions  of  blood  on  the  surface  of  the  body.  The 
skin  then  presents  a  greater  or  less  number  of  small  spots  or  pe- 
techias, of  a  violet  color,  and  almost  always  of  a  round  shape. 

This  disease  is  ordinarily  apyrectic,  particularly  in  children. 
It  may  be  simple,  that  is  to  say,  unaccompanied  with  any  general 
or  particular  symptoms  during  its  commencement,  development, 
or  termination ;  or  it  may  be  complicated  with  symptoms  of  a 
nature  more  or  less  serious,  such  as  hemorrhages  from  the 
gums,  stomach,  intestines,  or  bladder,  or  even  with  inflammation 
of  these  organs. 

I  saw  this  petechial  disease  in  two  young  infants,  who  exhi- 
bited a  condition  of  debility  and  prostration  in  a  very  marked 
manner  :  one  of  them,  eight  days  old,  revived  after  the  disappear- 
ance of  the  petechiae,  which  faded,  by  degrees,  assuming  succes- 
sively a  kind  of  black,  livid,  and  finally  a  yellow  color ;  the 
other,  younger,  more  feeble,  and  possessing  less  vivacity,  quick- 
ly succumbed.     The  following,  is  the  examination  of  the  case. 

CASE  II. — Delariie,  a  female  child,  was  deposited  at  the  Found- 
ling Hospital,  on  the  27th  of  March,  1829.     A  billet  fastened  to  the 

*  Praxis  med.     Lib.  17. 

t  Opera  med.     See  note  65,  chap,  iii.,  De  varioUs  et  anthracibus. 

t  Traite  thtorique  et  pratique  des  maladies  de  la  peau,  fonde  sur  de  nouvelles  re- 
cherche d^ anatomic  et  de  physiologie  pathologigue.  Paris,  1827.  2  vol.  avec  planches 
colorieea. 


ON   THE    DISEASES    OF    INFANTS.  11 

arm,  indicated  her  age  to  be  three  days  ;  she  was  strong,  and  large  ; 
color  slightly  jaundiced,  respiration  but  little  developed;  the  cry 
scarcely  heard ;  the  inferior  extremities  were  (Edematous.  The  face, 
trunk,  arms,  and  legs,  were  covered  with  violet-colored  petechiae  of 
various  sizes,  from  that  of  a  point  to  a  lentil.  The  unequal  manner 
in  which  they  were  disseminated,  and  the  intervals  of  yellow  between 
them,  gave  to  the  bod/  the  appearance  of  a  tiger's  skin.  She  re- 
mained in  this  state  for  two  days,  drinking  a  few  drops  of  milk, 
crying  with  difficulty,  and  respiring  but  little.  She  died  on  the 
evening  of  the  29th  of  March.  The  examination  of  the  body  was 
made  on  the  succeeding  day. 

Digestive  apparatus. — The  stomach  was  filled  with  a  considerable 
quantity  of  black,  viscid  blood  ;  its  internal  surface,  together  with 
that  of  the  jejunum,  was  filled  with  a  number  of  petechiae  like  those 
on  the  exterior  of  the  body.  Effusions  of  blood  were  found  in  dif- 
ferent parts  of  the  interior  surface  of  the  intestinal  canal,  the  mucous 
membrane  exhibited  at  the  parts  corresponding  with  these  efi'usions, 
petechial  ecchymoses  resembling  those  of  the  stomach ;  the  termi- 
nation of  the  ileon  contained  blood  rather  more  black,  and  more 
fluent ;  the  large  intestines  presented  a  well-defined  follicular  erup- 
tion ;  and  at  their  termination,  there  was  a  considerable  quantity  of 
blood  ;  the  walls  were  thick  and  firm. 

The  spleen  was  very  large,  and  very  much  engorged  Avith  blood ; 
it  presented,  near  the  entrance  of  the  small  vessels,  an  oblong  su- 
perficial rupture,  on  the  surface  of  which,  there  adhered  a  little  solid 
clot  of  blood.  In  the  cavity  of  the  abdomen,  was  found  a  large  table- 
spoonful  of  blood,  efiused  probably  by  the  rupture  of  the  spleen. 

The  heart  was  very  large,  and  engorged  with  blood,  and  the  surface 
covered  with  petechiae  ;  a  yellow  serum  was  contained  in  the  peri- 
cardium ;  the  pleura  was  spread  over  with  petechial  spots.  The 
usual  foetal  openings  still  continued  unclosed ;  the  lungs  were  en- 
gorged, the  kidneys  and  the  bladder  had  on  them  likewise  a  number 
of  ecchymosed  spots.     The  cerebrum  was  very  highly  congested. 

The  cellular  tissue  of  the  limbs  and  the  integuments  of  the  abdo- 
men, presented  large  ecchymoses,  and  blood  was  infiltrated  through- 
out the  tissue. 

The  condition  of  this  child  was  analogous  to  those  which 
Werlhof  has  noticed  in  adults,  and  of  which  I  also  have  given 
examples  in  another  work.*     These  different  sanguineous  effu- 

*  De  la  membr.  muq.  gastro-intest.  Paris,  1825. 


78  ON   THE    DISEASES   OP    INFANTS. 

sions  are  doubtless  the  effect  of  the  plethoric  state  in  which  this 
child  was  born,  and  particularly  of  the  congested  condition  of  the 
circulatory  and  respiratory  apparatus.  The  coincidence  of  the 
sanguineous  exhalation  on  both  the  external  and  internal  surfa- 
ces, is  worthy  of  notice. 

For  the  treatment  of  this  disease,  acidulated  and  diluent  drinks 
are  usually  advised.  In  children  who  exhibit,  like  the  one  whose 
case  has  just  been  described,  a  well  marked  sanguineous  conges- 
tion, the  best  application,  without  doubt,  would  be  a  few  leeches 
to  the  arms,  to  diminish  the  quantity  of  blood  in  the  seat  of  the 
disease.  When  hemacelinosis  is  simple,  it  had  better  be  left  to 
nature. 

I  once  saw  upon  the  inferior  extremities  of  a  child  aged  eight 
months,  much  emaciated  and  affected  with  a  chronic  inflamma- 
tion of  the  mesenteric  glands,  several  ecchymosed  spots  of  a  violet 
color,  developed  spontaneously,  analogous  to  marks  of  a  scorbu- 
tic character,  which  appear  on  the  limbs  of  old  people  reduced  by 
age  and  suffering. 

Of  some  alterations  of  the  color  of  the  skin, — Alterations  of 
the  color  of  the  skin,  are  usually  the  effects  of  age  or  of  disease. 
They  are  rarely  to  be  seen  on  sucking  infants;  still  there  may 
occur  at  this  tender  age,  the  different  varieties  of  lentigo,  ephel- 
ides,  etc. ;  but  as  these  various  alterations  of  color  are  common  to 
all  ages,  I  must  refer  to  the  works  of  Franck,  Lorry,  Bateman,  Al- 
ibert,  and  Rayer. 

Section    III. 

INFLAMMATIONS    OF   THE   SKIN. 

6ome  are  developed  in  the  uterus,  and  the  child  is  born  with 
them ;  and  others  do  not  occur  until  after  birth. 

Congenital  inflammations  of  the  skin. — Physicians  have,  for 
a  long  time,  described  different  eruptions  that  appear  on  the  body 
of  a  new-born  child.  Almost  all  are  regarded  as  syphilitic,  al- 
though often  they  are  not  so  ;  and  it  is  in  works  that  treat  par- 
ticularly of  venereal  diseases,  that  we  find  examples  of  congenital 
cutaneous  inflammations :  accoucheurs  also  have  mentioned 
them.  Infants  have  sometimes  been  born  with  measles ;  Vogel, 
says  Rayer,   asserts  that  he  has  seen  children  born  with   the 


ON    THE    DISEASES    OF    INFANTS.  79 

traces  of  measles  upon  them.  Duges  has  reported,  in  his  Inau- 
gural Dissertation,  several  cases  of  cutaneous  phlegmasioB  on  the 
bodies  of  infants  at  the  Hospice  de  la  Maternite.  I  have  seen  in 
a  young  infant,  an  erythema  under  the  form  of  small  irregular 
patches,  disseminated  upon  different  parts  of  the  body,  the  ap- 
pearance of  which  resembled  much  that  of  measles.  Small- pox 
has  been  developed  while  the  child  was  within  the  uterus.*  Jen- 
ner  has  recorded  in  the  first  volume  of  Medico- Chinirgical 
Transoxtions,  a  case  of  congenital  variola,  occurring  in  an  in- 
fant born  on  the  11th  of  June,  1808,  whose  mother  had  been 
vaccinated  on  the  6th  of  May.  The  body  of  this  child  was  cover- 
ed with  the  beginning  of  the  eruption.  New  variolous  pustules  ap- 
peared the  day  after  birth,  and  the  child  died  on  the  eighth  day 
in  convulsions. 

I  saw  at  London,  in  the  Anatomical  Museum  of  Astley  Coop- 
er, at  Guy's  Hospital,  a  foetus  preserved  in  alcohol,  the  body  of 
which  was  covered  with  well-marked  variolous  pustules.  Dr. 
Hodgkin,  conservator  of  the  Museum,  communicated  to  me  some 
very  interesting  facts  in  relation  to  this  case,  of  the  authenticity 
of  which  I  was  well  assured,  as  they  were  duly  recorded  in  the 
register  containing  the  history  of  the  principal  articles  contained 
in  this  Museum;  these  details  were  furnished, 'together  with  the 
preparation,  by  Dr.  Jos.  Laird. 

CASE  III. — Hannah  Howard,  aged  26  years,  was  attacked  with  the 
small-pox,  while  pregnant  with  her  second  child,  about  the  middle  of 
the  fifth  month.  She  became  sick  on  the  28th  of  August,  1805,  and 
the  eruption  appeared  on  the  30th.  She  entered  the  general  dispen- 
sary, in  Aldergate-street,  on  the  2d  of  September.  The  pustules  were 
confluent,  and  formed,  as  we  may  say,  but  one  crust  on  the  face  and 
arms.  They  were  distinct  upon  the  trunk  and  inferior  extremities, 
where  they  appeared  projecting  and  surrounded  by  a  red  circle.  The 
symptoms  were  those  which  usually  accompany  small-pox.  The 
bowels  were  maintained  in  a  soluble  condition,  opiates  were  adminis- 
tered, and  cold  and  acidulated  drinks  freely  given.  In  ten  days  after 
the  desquamation,  she  was  convalescent ;  was  able  to  walk  about, 
and  felt  the  movement  of  the  child  three  or  four  times  ;  but  since 

*  Moriceau,  "Watson,  and  Sydenham  have  given  examples  of  this ;  they  have  seen 
children  covered  with  variolous  eruptions  born  of  healthy  mothers. 


80  ON    THE    DISEASES    OF    INFANTS. 

that  time  she  experienced  no  motion,  and  on  the  28th  of  September, 
was  delivered  of  a  fcetus,  which,  from  its  size  and  form,  appeared  to 
be  about  six  months  old.  It  had  been  dead  probably  for  some  time, 
for  the  skin  of  the  abdomen  and  hands  was  raised,  and  it  presented 
some  evidences  of  putrefaction.  On  the  back  and  shoulders,  and 
more  particularly  on  the  superior  part  of  the  thighs,  where  the  in- 
teguments were  in  a  good  state  of  preservation,  there  were  several 
very  distinct  pustules,  characterized  by  their  round  borders,  slight- 
ly projecting,  and  their  depressed  centre;  the  placenta  was  not 
examined. 

This  case  appears  to  me  interesting  in  two  respects  :  it  proves, 
in  the  first  place,  the  communication  of  diseases  from  the  mother 
to  the  child ;  and,  in  the  second  place,  the  possibility  of  the  de- 
velopment of  diseases  during  the  intra-uterine  life,  analogous  to 
those  Avith  which  adults,  or  children  after  birth,  are  attacked.* 

I  do  not  intend  to  enumerate  here  all  the  congenital  cutaneous 
diseases  noticed  by  authors,  and  will  conclude  by  referring  to  a 
curious  case  of  pemphigus,  observed  by  M.  Lobstein,  of  Stras- 
bourg,t  and  which  M.  Duges  erroneously  considered  as  a  syphi- 
litic affection.! 

I  shall  give  below  the  characters  of  cutaneous  diseases  ;  it  will 
be  easy  after  that  to  arrange  those  of  infants  in  the  classes,  gene- 
ra, and  species  in  which  they  belong,  and  thus  to  devote  more 
attention  to  them. 

Section  IY. 

inflammations  developed  after  birth. 

Authors,  in  general,  have  not  sufiiciently  urged  the  considera- 
tion of  the  cutaneous  phlegmasise  of  new-born  and  sucking 
children.  Still  they  are  numerous ;  and  as  it  is  important  to  be 
well  acquainted  with  them,  that  they  may  not  be  confounded 
with  congenital  syphilis,  which  often  shows  itself  in  this  form,  I 
have  thought  it  incumbent  on  me  to  trace  their  history  with  pe- 

*  Analogous  cases  are  to  be  found  in  Bartholin,  {Epist.  med.  cent  2,  p.  682,)  and 
in  Philos.  trans,  abridged^  v.  3,  p.  308.  Boerhaave,  also,  speaks  of  having  seen  a 
similar  case.     Van  Swioten,  Variolce.     See  appendix, 

t  Journal  complementaire  du  Diet,  des  Sciences  med.  Tom.  6,  p.  3. 

t  Maladies  les  plus  importantes  et  les  moins  connucs  des  nouveau  nes.  Disserta- 
tion inaugurale.     Paris,  1821. 


ON   THE    DISEASES    OF    INFANTSi  81 

culiar  care.  In  order  to  facilitate  the  diagnosis,  I  have  followed 
a  particular  method,  of  which  I  shall  now  proceed  to  give  some 
idea. 

Considering  the  great  number  of  classes,  genera,  and  species, 
according  to  which  modern  authors,  more  especially  Willan  and 
Bateman,  have  arranged  cutaneous  phlegmasiae,  I  have  thought 
that  the  method  proposed  by  M.  Lamark  for  the  examination  of 
the  classes,  genera,  and  families  of  plants,  might  be  advanta- 
geously applied  to  the  study  of  the  subject  before  us.  It  is  well 
known  that  this  celebrated  naturalist  has  placed  all  the  known 
plants  in  successive  divisions,  exposed  in  such  a  manner  as  to 
leave  always  a  choice  between  two  contrary  propositions,  so  that 
the  observer  selects  one  of  the  two  propositions  agreeing  best  with 
the  subject  under  examination  ;  he  then  finds  one  for  reference, 
which  conducts  him  to  propositions  or  descriptions  successively 
and  constantly  opposed,  finally  arriving  at  that  which  gives  him 
the  most  exact  description  of  the  object  of  his  search,  and  enables 
him  in  this  manner  to  assign  to  it  the  class,  genus,  and  species, 
to  which  it  belongs. 

My  object  is  to  follow  nearly  the  same  course  in  the  exposition 
of  the  diseases  of  the  skin ;  and,  in  order  to  accomplish  it,  I  will 
trace  in  the  synoptical  tables  the  opposing  characters  of  the  classes, 
genera,  and  species  of  inflammations  of  the  skin,  arranged  accord- 
ing to  the  classification  of  Willan  and  Bateman,  modified  by  the 
more  recent  work  of  MM.  Biett  and  Rayer.  The  reader  finding 
himself  conducted  by  the  signs  or  numbers,  to  the  successive  ta- 
bles, will  gradually  arrive  at  the  characters  of  the  class,  genus, 
and  species  of  the  disease  of  which  he  is  in  search. 

With  Rayer,  I  denominate  inflammation  of  the  skin  all  dis- 
eases characterized,  at  their  commencement,  by  an  accumulation 
of  blood  in  one  part  or  in  the  whole  of  the  surface  of  this  mem- 
brane ;  an  alteration  followed  by  a  complete  resolution,  desqua- 
mation, morbid  secretion,  ulceration,  induration,  or  other  changes 

in  the  organization  of  the  part  affected. 

u 


82 


ON  THE  DISEASES  OP   INFANTS. 


TABLE   FIRST— CLASSES. 


INFLAMMATIONS. 


1.  Redness,  more  or  less  viv- 
id, resulting  from  a  morbid  ac- 
cumulation of  blood  in  the  in- 
teguments, to  a  greater  or  less 
extent,  with  or  without  tume- 
faction ;  without  pimples,  usual- 
ly disappearing  under  the  pres- 
sure of  the  finger,  and  reappear- 
ing when  the  pressure  is  remov- 
ed. 

EXANTHEMATOUS    INFLAM- 
MATIONS. 

See  A.  Table  2d. 

3.  Transparent  vesicles  form- 
ing small  serous  elevations  less 
voluminous  than  bullae,  result- 
ing from  a  drop  of  serum  effus- 
ed between  the  epidermis  and 
the  corpus  reticulare ;  on  being 
ruptured,  the  contents  flow  out, 
accompanied  or  followed  by  su- 
perficial excoriations  of  thin  and 
lamellated  crusts. 

VESICULAR     INFLAMMATIONS. 

See  C.  Table  2d. 

5.  Elevations  small,  firm^ 
rounds  color  corresponding  with 
that  of  the  skin,  accompanied 
by  itching,  more  or  less  severe, 


2.  Redness,  more  or  less  viv- 
id, of  variable  extent,  preceded 
or  accompanied  by  small  tu- 
mors, formed  by  an  accumula- 
tion of  serum  or  of  sero-puru- 
lent  matter  accumulated  be- 
tween the  epedermis  and  the  in- 
flamed corpus  reticulare. 


BULLOUS     INFLAMMATIONS. 

See  B.  Table  2d. 


4.  Elevations  from  one  line 
to  three  lines  in  diameter,  usual- 
ly circumscribed  and  not  trans- 
parent, often  surrounded  by  an 
inflamed  areola,  and  formed  by 
pus  deposited  between  the  epi- 
dermis and  the  corpus  reticu- 
lare. They  terminate  by  desic- 
cation, ulceration,  and  indura- 
tion. 

PUSTULAR    INFLAMMATION. 

See  D.  Table  2d. 

6.  Elevations  or  tumors  solid, 
resisting,  circumscribed,  indu- 
rated, lasting,  more  voluminous 
than  papulas,  and  almost  always 


ON   THE    DISEASES    OF    INFANTS. 


83 


ordinarily  terminating  in  reso- 
lution and  furfuraceous  des- 
quamation, and  sometimes  in 
small  ulcerations. 

PAPULAR     INFLAMMATIONS. 

See  E.  Table  2d. 

7.  Elevations  and  red  spots 
largely  prominent,  little  hard- 
ness to  the  touch,  continually 
covered  with  scales  of  the  alter- 
ed epidermis,  which  are  con- 
stantly detached  from  the  sur- 
face of  the  skin. 

SaUAMOUS    INFLAMMATIONS. 

SeeG.  Table  2d. 

9.  Redness  circumscribed, 
painful  to  the  touch,  accompa- 
nied by  a  base,  and  soon  by  a 
puffiness  of  the  subcutaneous 
cellular  tissue,  usually  terminat- 
ing in  suppuration. 

FURUNCULOUS  INFLAMMATIONS. 

Seel.  Table  2d. 


11.  Redness  and  alteration  of 
the  tissue  more  or  less  analo- 
gous to  the  general  characters  of 
other  species  of  inflammations, 
and  presenting  in  their  phases 
much  more  variety  of  form  and 
aspect.  These  are  usually 
caused  by  excess  of  cold  or  of 
heat. 

INFLAMMATION    FROM  COMBUS- 
TION OR  CONGELATION. 

See  K.  Table  2d. 


terminating  in   suppuration   or 
ulceration. 

TUBERCULAR    INFLAMMATIONS. 

See  F.  Table  2d. 


8.  Redness  diffused,  ordinari- 
ly of  little  intensity,  sometimes 
succeeded  by  other  inflamma- 
tions, and  characterized  by 
spontaneous  linear  divisions  of 
the  skin,  in  those  parts  alone 
where  it  is  developed. 

LINEAR    INFLAMMATIONS. 

See  H.  Table  2d. 

10.  Redness,  at  first  more  or 
less  vivid  and  painful,  after- 
wards suddenly  violet,  livid,  or 
blackish,  with  but  little  or  no 
pain,  terminating  rapidly  in 
mortification  of  the  skin  to  a 
greater  or  less  extent. 

GANGRENOUS    INFLAMMATIONS. 

See  J.  Table  2d. 

12.  Redness  variable,  altera- 
tions of  the  skin,  difiicult  to  re- 
fer to  any  ordinary  forms  of  in- 
flammation, having  a  continual 
tendency  to  extend  or  to  reap- 
pear, observed  in  children  of 
suspicious  parents. 

SYPHILITIC    AFFECTIONS. 

See  L.  Table  2d. 


84 


ON  THE   DISEASES  OP   INFANTS. 


TABLE  SECOND— GENERA. 

INFLAMMATIONS. 
A.      EXANTHEMATOUS    INFLAMMATIONS. 


1.  Red  spots,  of  a  few  lines  to 
several  inches  in  diameter,  with- 
out tumefaction  of  the  subcuta- 
neous cellular  tissue,  sometimes 
so  numerous  as  to  produce  a  ge- 
neral red  tint  over  the  skin. 
This  is  the  first  of  a  great  num- 
ber of  phlegmasiae  of  the  integu- 
ments. This  redness^  ordinarily 
transient^  is  generally  develop- 
ed on  those  parts  habitually  in 
contact  loith  urine,  fecal  matter, 

ERYTHEMA.     See  p.  95. 


3.  Small  red  points,  soon  re- 
placed by  large  scarlet  patches, 
indented  at  their  borders,  the 
exanthema  soon  becomes  con- 
tinued ;  the  skin  is  burning,  dry, 
and  sensibly  reddens  to  the 
touch.  Color  deeper  at  night; 
the  surface  of  the  body  appears 


2.  Tint  of  the  skin  of  a  deep 
red,  with  tumefaction  of  the 
subcutaneous  celhdar  tissue. 
The  redness  does  not  consist  of 
small  patches,  but  of  a  large 
sheet.  Irregularly  circumscrib- 
ed, it  uniformly  occupies  a  por- 
tion of  the  limbs,  trunk,  or  face,  to 
a  greater  or  less  extent.  It  is  of- 
ten accompanied  with, fever  and 
gastric  or  cerebral  symptoms. 
The  redness  always  moves  from 
one  place  to  another,  and  is  co- 
vered with  phlycteenae  (phlycte- 
noid  erysip.) ;  the  inflammation 
extends  itself  in  the  cellular 
tissue,  producing  suppuration 
(phlegmonous  erysip.) ;  eschars 
form  (gangrenous  erysip.) ;  limbs 
are  infiltrated  (cedematous  ery- 
sip.) 

ERYSIPELAS.       ScC  p.  98. 

4.  Patches  prominent,  paler 
than  the  surroundmg  skin,  ac- 
companied with  itching;  the 
patches  appear  first  on  the  limb, 
then  upon  the  trunk;  their 
form,  number,  and  extent,  vary 
much.  They  resemble  the 
marks    produced    by     nettles. 


ON    THE    DISEASES   OF    INFANTS. 


85 


then  as  if  it  had  been  daubed 
with  the  juice  of  strawberries. 
It  has  three  periods :  incubation, 
development,  and  desc[uama- 
tion ;  ordinary  complication, 
simple  or  malignant  angina. 

SCARLATINA.       ScC  p.  104. 

5.  First  period.  During  the 
existence  of  the  symptoms  of 
angina  or  pneumonia,  small  red 
spots  are  to  be  observed,  distinct, 
almost  circular,  resembling  flea- 
bites  ;  they  appear  first  on  the 
forehead,  chin,  nose,  etc.,  then 
spread  on  the  neck  and  limbs ; 
they  are  accompanied  by  fever 
and  itching,  and  great  heat  of 
the  skin.  Second  period  :  other 
semicircular  patches  ?ningle 
with  the  first ;  theij  do  not  give 
on  touching  them,  with  the  fin- 
ger the  sensation  of  a  promi- 
nent surface.  In  the  interstices, 
the  skin  preserves  its  natural 
tint.  Third  period  :  at  the  end 
of  four  or  five  days,  when  the 
redness  has  disappeared,  a  slight 
desquamation  ensues,  accom- 
panied with  itching. 

RUBEOLA.     See  p.  101. 


Very  rarely  followed  by    des- 
quamation. 

URTICARIA.     See  p.  106. 


6.  Patches,  rose-colored,  vari- 
ously figured,  not  prominent, 
much  larger  and  more  irregular, 
separated  by  a  number  of  spa- 
ces ;  sometimes  the  patches  are 
annular ;  they  are  at  first  of  a 
pretty  dark  red,  soon  becoming 
rose-colored.  They  are  accom- 
panied with  itching,  but  no  irri- 
tation nor  smarting ;  the  inflam- 
mation is  more  deeply  stamped 
than  in  erythema ;  it  is  scarcely 
ever  followed  by  desquamation ; 
it  is  not  contagious. 

ROSEOLA.    See  p.  103, 


B. 


BULLOUS    INFLAMMATIONS. 


1.  Large  bullae  without  an 
areola,  preceded  by  a  simple 
erythematic  redness,  constantly 
followed  by  a  denudation  of  the 
inflamed  corpus  reticulare,  with 
suppuration,  more  or  less  abund- 


2.  Tumors  solitary,  in  small 
numbers,  formed  by  an  effusion 
of  sero-purulent  fluid  between 
the  epedermis,  developed  in  parts 
that  have  been  violently  rubbed, 
accompanied  with  redness  and 


86 


ON   THE    DISEASES    OF    INFANTS. 


ant,  and  sonaetimes  with  a  mem- 
biani-form  excretion  caused  by 
blisters. 

VEsicATORiA.     See  p.  108. 

3.  One  or  more  voluminous, 
yellow,  and  transparent  bullae, 
the  eruption  of  which  may  be 
either  simultaneous  or  progres- 
sive, terminating  by  an  eifusion 
of  lymph,  which  concretes  and 
forms  a  yellow  scab,  or  gives 
rise  to  a  superficial  ulcer  ;  these 
bullae  are  usually  round,  and 
are  preceded  by  red  spots  but 
slightly  prominent.  The  areolae 
formed  by  the  disks  of  the  eryth- 
matic  spots,  disappear  during  the 
growth  of  the  bullae.  The  skin 
is  not  deeply  inflamed,  neither 
has  it  any  tendency  to  form  deep 
ulcerations. 

PEMPHiGis  (acute  or  chronic.) 
See  p.  108. 

5.  Inflamed  vesicles  and  bul- 
lae, surrounded  by  a  small  red 
circle,  appearing  particularly  on 
one  side  of  the  trunk,  disposed 
in  the  form  of  a  band,  producing 
a  great  itching;  the  vesicles  open, 
ulcerate,  and  form  yellow  or 
black  scabs. 

ZONA.    See  p.  102. 


heat ;   a  thick 


fluid  flows    out 
when  they  are  broken. 
ESSERA.     See  p.  108. 


4.  Small  bullae,  the  bases  of 
which  are  inflamed,  few  in  num- 
ber, flat,  and  filled  with  a  fluid, 
at  first  serous,  but  soon  thick, 
sanguinolent,  drying  in  the  form 
of  black  scab.  The  skin  beneath 
them  has  a  strong  tendency  to 
ulcerate.  The  ulcers  become 
atonic,  and  are  to  be  observed  in 
badly  nourished,  debilitated,  scro- 
fulous individuals. 

RUPiA.     See  p.  111. 


C.      VESICULAR   INFLAMMATIONS. 


1.  Globular  and  transparent 
vesicles,  filled  with  a  colorless, 
or  citron-colored  fluid,  of  the 


2.  Small  vesicles,  very  near 
each  other,  ordinarily  whitish 
and  very  evident,  accompanied 


ON  THE  DISEASES  OF  INFANTS. 


87 


size  of  a  grain  of  millet  seed,  ap- 
pearing in  groups^  more  or  less 
numerous^  in  different  parts  of 
the  hody^  accompanied  v/ith 
prickling,  and  separated  by  in- 
tervals, where  the  skin  is  often 
the  seat  of  an  inflammation, 
which  only  occurs  in  the  inter- 
stices of  the  vesicles  forming  the 
group.  These  groups  are  irre- 
gular, arranged  in  a  circle,  or  in 
the  form  of  a  crown. 

Herpes.     See  p.  112. 

3.  Contagious  vesicles,  apy- 
rectic,  slightly  elevated  above 
the  level  of  the  skin,  color  but 
little  altered;  transparent  at  their 
summits,  accompanied  toitk  an 
itching  which  compels  the  pa- 
tient to  be  continually  scratch- 
ing ;  more  particularly  devel- 
oped in  the  folds  of  the  articu- 
lations. 

PSORA.     See  p.  116. 


by  a  redness  and  tension  of  the 
skin,  terminating  by  a  re-absorp- 
tion of  the  fluid  contained  in 
them,  or  by  a  rupture  of  the 
vesicles  ;  succeeded  by  serous  ex- 
udation^ more  or  less  abundant; 
the  skin  covered  with  very  su- 
perficial scabs,  formed  by  the 
destruction  of  the  epidermis,  and 
the  concretion  of  the  excreted 
fluid. 

Eczema.     See  p.  113. 

4.  Pearl-colored  vesicles,  about 
the  size  of  millet  seeds,  formed 
in  great  numbers  epidemically, 
accompanied  with  fever,  gastro- 
intestinal inflammation,  sweat 
abundant  and  foetid,  and  with 
great  irritation  of  the  skin. 

MILIARY    sweat.       ScC  p.    117. 


D. 


PUSTULAR    INFLAMMATIONS. 


1.  After  a  fever  of  14  to  48 
hours,  accompanied  with  gastro- 
intestinal irritation,  small  oblongs 
flattened^  red  spots  are  seen,  giv- 
ing to  the  touch  the  sensation 
of  a  flattened  seed,  in  the  centre 
of  which  a  prominent  vesicle  is 
formed^  containing  a  colorless^ 
or  a  citron-colored  humor.  Soon 
the  base  of  the  vesicle  inflames, 
the  vesicles  break  and  leave  in 
their  place  a  yellow  scab ;  these 
vesicles  may  be  conical,  globu- 


2.  After  symptoms  of  gastro- 
pulmonary  and  intestinal  inflam- 
mation of  two  or  three  days'  du- 
ration, small  pustules  appear,  at 
first  pointed,  but  soon  become 
umbilicated,  distinct,  and  some- 
times confluent.  At  the  same 
time  that  the  pustules  assume  an 
umbilicated  form,  and  their  cen- 
tre becomes  puriform,  the  skin 
reddens  and  tumifies  in  a  very 
remarkable  manner.  At  the 
end  of  eight  or  ten  days,  the 


88 


ON   THE    DISEASES   OP   INFANTS. 


lar^  or  umbilicated.  In  general 
the  duration  of  these  pustules  is 
only  six  or  eight  days ;  they 
have  but  one  form  during  their 
various  periods ;  they  are  al- 
ways either  conical,  globular, 
or  umbilicated. 

VARICELLA.    See  p.  117. 


3.  "After  the  insertion  in  the 
skin  of  a  fluid  taken  from  pus- 
tules on  the  teats  of  a  cow, 
there  appears  at  the  end  of  eight 
days  an  elevated  redness,  which 
soon  contains  a  fluids  at  first 
transparent^  afterwards  thick; 
the  centre  of  these  pustules  are 
depressed,  their  bases  inflame 
and  tumify,  and  finally  the  hu- 
mor' they  contain  is  transform- 
ed into  a  brow7i  scab,  which  de- 
taches itself  about  the  twelfth* 
day,  and  afterwards  leaves  a 
cicatrix. 

VACCINIA.     See  p.  120. 

5.  Large  pustules  elevated  on 
a  hard,  circular,  and  very 
red  base,  ordinarily  separate, 
and  appearing  successively  in 
various  parts  of  the  body.   They 


pustules  begin  to  dry,  and  are 
covered  with  yellow  or  black 
scabs.  After  the  fall  of  the 
scabs,  circular  spots  appear  on 
the  skin,  of  a  reddish  brown, 
afterwards  cicatrices,  more  or 
less  regular;  sometimes  there 
occurs  an  abundant  ptyalism. 
In  general  the  duration  of  these 
pustules  is  from  twelve  to  fif- 
teen days.  The  pustules  at  first 
acuminated,  do  not  become  um- 
bilicated, except  during  their 
progress. 

VARIOLA.     See  p.  117. 

4.  After  the  insertion  of  the 
vaccine-virus  in  persons  pre- 
viously vaccinated,  or  who  have 
had  the  small-pox,  there  appear 
circidar  ijustides,  the  borders 
of  lohich  are  flattened  and  irre- 
3  ular,  ajid  are  not  swelled,  con- 
taining in  their  centre  a  lim- 
pid yelloio  humor.  These  pus- 
tules are  accompanied  with  an 
insupportable  itching ;  from  the 
seventh  to  the  eighth  day,  scabs 
form  and  fall  off"  without  leav- 
inof  a  cicatrix. 

vAcciNELLA.     See  p.  120. 


6.  Pustules,  slowly  forming 
in  the  inidst  of  a  reddish,  and 
sometimes  violet,  induration, 
which  are  to  be  seen  on  the 
cheeks,  in  the  forehead,  and  on 


'  ♦  This  is  evidently  an  error,  the  scab  scarcely  ever  becoming  detached  before  the  2lst 
day.—S. 


ON  THE    DISEASES    OF    INFANTS. 


89 


are  soon  covered  with  hro^on 
scabsj  thick  and  adherent,  be- 
neath which  there  forms  either 
a  cicatrix  or  an  ulceration. 
They  often  leave  after  them  a 
chronic  induration;  they  are 
developed  more  particularly  in 
debilitated  subjects. 

ECTHYMA.     See  p.  121. 

7.  Small  superficial  pustules 
irregularly  disseniitiated  on 
the  scalp,  where  they  exclusively 
exist;  at  first  they  are  humid 
arid  irregular ;  to  the  pustules 
succeed  gray  or  brown  scabs, 
which  are  never  dejjressed,  the 
fragments  of  which  are  often 
found  disseminated  among  the 
hair.  When  these  scabs  run 
together,  and  dry,  they  become 
hard,  and  are  strongly  attached 
to  the  hair  with  which  they  are 
intermingled.  They  are  rarely 
communicated  by  contact. 

TINEA  GRANULATA.    ScC  p.  127. 

9.  To  a  number  of  small  red 
pimples,  scarcely  elevated  above 
the  level  of  the  skin,  small  yel- 
low pustules  succeed,  the  sum- 
mits of  which  are  immediately 
covered  with  irregularly  circu- 
lar scabs,  strongly  adhereyit,  at 
first  yellow,  afterwards  brown- 
ish, and  always  cupped  in  the 
centre.  These  pustules  are 
sometimes  separated  and  some- 
times agglomerated.  They  are 
particularly  to  be  seen  on  the 
scalp ;  yet  they  may  appear  on 


the  nose.  Sometimes  these  pus- 
tules are  intermingled  with 
small  black  points,  formed  by 
an  alteration  of  the  foUicles  of 
the  face ;  these  pustules  are 
7iever  covered  with  scabs,  and 
they  almost  always  dry  without 
ulceration. 

ACNE.     See  p.  122. 

8.  Small  pustules,  disposed  in 
irregular  groups,  developed  on 
the  face  and  on  the  scalp,  fur- 
nishing a  large  quantity  of  hu- 
mor, adhering  closely  to  the 
hair,  at  first  white,  and  but  lit- 
tle projecting  ;  they  break,  and 
are  surrounded  with  red  in- 
flamrnatory  patches ;  a  red  or 
greenish  fluid  issues  from  them, 
which  is  transformed  into  thin 
and  yellow  scabs,  which,  by  an 
accumulation  of  a  viscid  hu- 
mor, forms  sometimes  a  perfect 
mask. 

PORRIGO  LARVALIS.    SOC   p.  127. 

10.  Circidar  groups  of  small 
yelloiu  pustules  on  the  scalp, 
elevated  in  the  middle  of  red  in- 
flamed spots.  The  centre  of 
the  jjusttdes  is  sometimes  tra- 
versed by  a  hair.  The  contents 
of  these  tumors  thicken  and 
form  scabs,  beneath  which  the 
skin  is  red  and  inflamed.  The 
inflammation  is  propagated  to 
the  tubes  of  the  hairs  ;  the  hair 
sometimes  falls,  but  is  after- 
wards reproduced ;  the  scabs 
are  never  hollotved  in  the  cen- 
12 


90 


ON   THE    DISEASES    OF    INFANTS. 


different  parts  of  the  body. 
These  scabs  emit  a  disagreea- 
ble odor  on  their  being  raised  ; 
beneath  them  will  be  found 
small  red  excoriations,  superfi- 
cial and  lenticular.  They  will 
produce,  after  a  length  of  time, 
a  general  or  local  baldness. 
PORRiGO  LUPiNOSA.  See  p.  124. 

11.  Pustules  acuminated,  de- 
veloping on  the  chin,  detach- 
ed on  a  base  of  a  vivid  red. 
The  pustules  are  preceded  by 
a  slight  smarting ;  little  red 
points  at  first  show  themselves  ; 
they  become  more  salient,  their 
summits  whiten,  rarely  exceed- 
ing the  size  of  a  millet  seed ; 
when  the  pustules  are  ruptured, 
an  oozing  takes  place,  produ- 
cing a  scab  but  slightly  adhe- 
rent. In  this  manner  occur  se- 
veral successive  eruptions;  the 
chin  and  side  of  the  face  are 
soon  covered  with  them,  the 
pustules  form  in  groups,  their 
bases  spread  and  thicken,  the 
scabs  augment,  but  they  are 
never  very  thick  nor  very  adhe- 
rent ;  the  subcutaneous  cellular 
tissue  inflames  and  becomes  the 
seat  of  phlegmonous  affections 
always  remarkable  for  their  red 
appearance. 

MENTAGRA.     See  p.  122. 


E.      PAPULAR    INFLAMMATIONS. 

1.  A  number  of  small   pirn- 1     2.   Small  papulae,  sometimes 
plesj  hard  to  the  touch,  com- {scarcely  visible,  ordinarily  acu- 


tre  ;  the  fluid  of  the  pustules  is 
always  contagious,  and  infects 
successively  various  parts  of  the 
integuments  of  the  cranium, 
where  it  is  carried  by  the  fin- 
gers of  the  patient. 

TINEA  ANNULARIS.    SCG  p.  127. 


12.  Small  pustules  agglome- 
rated or  distinct,  developing  on 
different  parts  of  the  body,  but 
more  especially  on  the  face ; 
they  consist  at  first  of  small  red 
spots,  in  the  centre  of  which  are 
formed  yellow  pustules  not  ac- 
uminated, accompanied  with  a 
great  itching ;  they  break  at  the 
end  of  five  or  six  days,  yielding 
a  yellow  fluid,  which  drying, 
resembles  concrete  honey.  The 
oozing  beneath  the  scabs  aug- 
ments their  thickness;  some- 
times several  eruptions  succeed. 
After  the  fall  of  the  scabs,  the 
skin  beneath  is  found  of  a  vio- 
let color,  covered  with  a  newly 
formed  epidermis. 

IMPETIGO.    See  p.  123, 


ON    THE    DISEASES    OF    INFANTS. 


91 


pact,  red  or  white,  forming  at 
first  on  the  face,  afterwards  on 
the  limbs,  particularly  in  in- 
fants at  the  breast,  never  termi- 
nating in  pustules,  scabs,  or 
ulceration,  but  leaving  some- 
times in  their  place  a  slight  ef- 
florescence, generally  accompa- 
nied by  a  great  itching;  they 
may  be  scanty,  intermingled 
with  patches  of  erythema,  or 
spread  in  great  numbers  over 
all  parts  of  the  body. 

STROPHULUS.     See  p.  130. 


3.  Papulae  scarcely  visible, 
causing  a  great  itching;  when 
torn  by  the  nails,  a  sero-sangui- 
nolent  fluid  issues,  which  con- 
cretes immediately,  and  forms  a 
small  black  scab,  sometimes  ac- 
companied with  fever ;  they  are 
always  the  seat  of  an  insupport- 
able itching. 

PRURIGO.     See  p.  128. 


minated,  and  hard  to  the  touch, 
containing  neither  pus  nor  se- 
rum, accompanied  by  a  disa- 
greeable sensation,  especially  in 
the  night ;  persisting  for  a  long 
time,  spread  over  the  face  and 
upon  different  parts  of  the  body, 
rarely  accompanied  with  febrile 
symptoms,  appearing  dissemina- 
ted or  sometimes  grouped  at 
the  root  of  the  hairs.  When 
they  dry,  they  give  rise  to  the 
secretion  of  a  fluid,  which  con- 
cretes 
They 

with  vesicles  or  pustules.     The 
nature   of  the  disease  may  al- 
ways be  known  by  the  presence 
of  papulae  about  the  scales. 
LICHEN.    See  p.  132. 


in  small    humid  scales, 
are    often    complicated 


F.       TUBERCULAR   INFLAMMATION. 


1.  One  or  more  tubercles,  of 
a  medium  size,  flat  or  promi- 
nent, of  a  livid  red,  terminating, 
after  several  months  or  years, 
in  ulceration,  secreting  ichorous 
pus,  the  concretion   of   which 


2.  Solitary  tubercles,  remain- 
ing a  long  time  indolent ;  they 
are  the  seat  of  lancinating  pain ; 
they  become  violet,  and  ulce- 
rate. The  ulcers  present  in- 
verted, 


hard,  or 


fungous  bor- 


92 


ON   THE    DISEASES   OP    INFANTS. 


solid,  adherent  yellow  scabs. 
The  ulceration  extends  in 
depth,  the  borders  remaining 
unequal  and  hard ;  they  are 
continually  covered  with  scabs, 
which  fall  of  themselves. 
LUPUS.     See  p.  133. 

3.  Numerous  indolent  tuber- 
cles, livid,  and  sometimes  of  the 
same  color  as  the  skin,  de- 
veloped principally  in  the  face 
and  the  ears,  as  well  as  on  the 
limbs.  These  tubercles  some- 
times ulcerate,  and  are  covered 
with  adherent  scabs,  beneath 
which  are  found  cicatrices  ;  the 
parts  on  which  these  tubercles 
are  developed,  acquire  an  in- 
crease of  size. 

GREEK    ELEPHANTIASIS. 

See  p.  133. 


ders  ;  a  sanious  pus  flows  from 
them,  and  they  diffuse  a  pecu- 
liar odor. 

CANCER.    See  p.  133. 


G.       SaUAMOUS    INFLAMMATIONS. 


1.  Scaly  plates,  almost  al- 
ways circular  J  of  a  whitish  co- 
lor, at  first  but  a  little  project- 
ing", resembling  small  spangles ; 
they  enlarge  and  rise ;  their  bor- 
ders^ surrounded  by  a  red  cir- 
cle^ are  prominent^  whilst  their 
centres  are  depressed  ;  they  af- 
terwards form  small  red  pim- 
ples, hard,  grouped,  but  never 
pustular  ; — simple  and  isolated, 
they  enlarge  and  multiply,  pre- 
serving always  their  white  and 
scaly  appearance,  together  with 
their  orbicular  form ;  they  cov- 
er, at  the  same  time,  one  part  or 


2.  Scaly  plates,  never  circu- 
lar^ of  a  red  color,  at  first  small 
and  projecting;  they  enlarge 
and  rise,  but  their  borders  are 
never  prominent,  nor  their  cen- 
tres depressed.  They  form  af- 
terwards, in  groups,  small  red 
pimples,  rarely  isolated ;  they 
multiply  promptly,  exhibiting 
an  irregidarly  circumscribed 
surface;  they  are  often  con- 
founded with  one  another,  ap- 
pearing in  several  parts  of  the 
body,  but  more  particularly  on 
the  face,  trunk,  and  head ;  the 
inflammation  of   the    reticular 


ON  THE    DISEASES   OP   INFANTS. 


93 


several  parts  of  the  body,  but 
appear  to  be  more  particularly 
developed  in  the  projections  and 


articulations 

LEPRA 


projections  and 
See  p.  133 


3.  Small  red  patches,  very 
thin,  covering  superficial  scabs, 
which  are  continually  detached 
in  small  fragments,  sometimes 
purulent,  and  almost  always  re- 
placed by  new  epidermic  des- 
quamations. It  is  usually  seated 
in  the  scalp. 

PTYRiASis.     See  p.  136. 


H.       LINEAR    INFLAMMATIONS. 

Linear  divisions  of  little  depth,  developed  usually  at  the  bot- 
tom of  the  folds  of  the  skin,  or  in  the  neighborhood  of  the  differ- 
ent natural  openings  of  the  body. 

FissuRA.     See  p.  136. 

I.       GANGRENOUS    INFLAMMATIONS. 


tissue  imparts  a  deej)er  tint  to 
the  scales,  which  are  sometimes 
cracked. 

PSORIASIS.     See  p.  133. 


1.  After  a  puncture  by  an  in- 
sect, or  with  an  instrument  with 
which  animals  have  been  killed, 
an  cedematous  tumefaction  of 
the  skin  is^  developed  in  a  cir- 
cumscribed point.  In  the  cen- 
tre of  this  tumefaction  appears 
a  violet  colored  ecchymosis, 
slightly  prominent,  beneath 
which  a  lenticular  induration  is 
formed,  which  is  soon  replaced 
by  a  reddish  areola ;  or  a  gan- 
grene, and  an  extensive  disor- 
ganization of  the  subcutaneous 
tissue  ensues.     The  patient,  re- 


2.  In  those  infants  where  the 
circulation  is  slow,  and  the  face 
and  extremities  blue,  cold,  and 
cedematous,  there  occurs  at  first 
about  the  toes  and  hands,  and 
afterwards  in  other  parts  of  the 
body,  an  obscure  redness  with- 
out tumefaction ;  the  skin  be- 
comes brown,  dries,  hardens, 
and  finally  presents  all  the 
characters  of  gangrene.  Dur- 
ing the  development  of  this 
disease,  the  infant,  respiring 
with  difficulty,  and  almost  in- 
animate, exhibits  all  the  precur- 


94 


ON   THE    DISEASES    OF    INFANTS. 


duced  to  extreme  debility,  has 
frequent  faintings,  and  in  the 
space  of  a  few  days  or  hours, 
will  be  brought  to  the  last  ex- 
tremity. 

MALIGNANT    PUSTULE. 

See  p.  138. 


sory  signs  of  death  from  slow 
asphyxia. 

INFANTILE    GANGRENE. 

See  p.  137. 


K.        INFLAMMATIONS    FROM    HEAT    AND   FROM    COLD. 


1.  Erythema,  erysipelas,  bul- 
lae, vesicles  or  gangrene,  pro- 
duced on  the  skin  by  caloric  or 
caustic. 

See  p.  138. 


2.  Erythema,  with  engorge- 
ment of  the  cellular  tissue,  bul- 
Ise,  fissura,  gangrene  ;  produced 
by  cold  on  parts  remote  from 
the  centre  of  circulation. 
See  p.  138. 


Li.       SYPHILITIC    AFFECTIONS. 

Some  of  the  species  of  diseases  above  described  may  assume  a 
syphilitic  character,  which  may  be  known  by  the  eruption  fol- 
lowing other  venereal  symptoms;  by  their  resisting  the  usual 
treatment  of  simple  cutaneous  diseases ;  by  their  constant  tenden- 
cy to  spread  and  ulcerate ;  by  their  exhibiting  a  cupreous  appear- 
ance, particularly  on  the  use  of  mercury,  sudorifics,  and  other 
remedies  used  for  the  treatment  of  syphilis  ;  and,  finally,  by  their 
manifestation  under  circumstances  proper  for  the  development  of 
the  venereal  disease. 

It  is  worth  observing,  that  among  all  the  cutaneous  diseases 
which  more  often  assume  a  venereal  character,  are  the  exanthe- 
mata, pustulse,  papul83,  and  tubercula.  On  the  other  hand,  of  all 
the  symptoms  produced  by  mercury,  cutaneous  affections  are  the 
most  frequent,  concurring  to  render  the  diagnosis  of  syphilitic  affec- 
tions and  mercurial  eruptions  both  obscure  and  difficult.  Phy- 
sicians ought,  on  this  account,  to  exercise  great  discrimination  in 
examining  the  cutaneous  diseases  of  young  infants ;  they  should 
not  forget  that  they  have  need  of  all  the  circumstances  connected 
with  the  case,  the  nature  and  mode  of  development  of  the  affec- 
tion they  are  called  to  treat,  to  enable  them  to  make  a  correct 
diagnosis,  since  the  anatomical  characters  are  very  variable,  often 


ON   THE    DISEASES    OF    INFANTS.  95 

deceiving,  and  are  not  of  themselves  sufficient  to  confirm  the 
judgment  of  the  physician. 


TABLE  THIRD.— SPECIES. 

ERYTHEMA. 

Erythema  intertrigo,  caused  by  the  contact  of  faecal  matters. 

«  combustioj      "        "   the  action  of  fire. 

«  pernio,  "        "    the  absence  of  caloric. 

«  paratrima,    "        "   lying  on  the  part. 

«  dpuncturdj   "        "    a  puncture. 

"  idiopathicum, 

"  symptomaticum. 

"  fugace, 

"  marginatum, 

"  papulatum, 

"  tuberculatum, 

"  nodosum. 

All  external  causes  capable  of  irritating  the  skin,  may  produce 
erythema,  in  some  of  the  numerous  varieties  mentioned  above. 
In  general  it  is  a  very  superficial  inflammation,  disappearing  with 
great  facility.  It  is  rarely  accompanied  with  any  general  de- 
rangement of  the  system. 

Erythema  produced  by  the  contact  of  fcEcal  matters,  is  more 
often  seen  in  new-born  children,  occupying  the  breech,  upper 
part  of  the  thighs,  and  scrotum  ;  suitable  care,  and  simple  emol- 
lient lotions,  are  sufficient  for  its  removal. 

If  it  be  very  severe,  seated  around  the  anus,  and  if  there  exist 
at  the  same  time  a  diarrhoea,  it  may  be  considered  as  a  symptom 
of  enteritis.     I  will  recur  to  this  subject  hereafter. 

During  the  exfoliation  of  the  epidermis,  the  skin  of  the  infant 
is  often  covered  with  erythematic  plates,  or  striae,  situated  in  the 
folds  of  the  joints.  The  scrotum  and  the  superior  parts  of  the 
thighs,  are  more  particularly  subject  to  these  affections. 

CASE  IV. — Induration  of  the  cellular  tissue,  erythema  of  the 
scrotum,  g astro-enteritis. — Marcanel,  aged  twelve  days,  a  male,  en- 


96  ON    THE    DISEASES    OF    INFANTS. 

tered  the  infirmary  on  the  10th  of  May.  This  child  was  very  small, 
and  was  affected  with  a  general  oedema ;  the  epidermic  exfoliation  was 
in  full  activity.  The  scrotum,  entirely  deprived  of  its  epidermis, 
was.  intensely  red  and  tumified  ;  the  superior  part  of  the  thighs  pre- 
sented the  same  appearance.  The  child  was  feeble,  his  cry  com- 
plete, but  scarcely  to  be  heard ;  respiration  tolerably  free,  and  the 
chest  sonorous  ;  the  face,  continually  drawn  up,  expressed  great 
pain  ;  the  alvine  dejections  were  abundant,  clear,  and  foetid  ;  the 
pulse  was  natural.  The  treatment  consisted  of  diluent  drinks  and 
bran  baths.  He  did  not  rally,  and  on  the  16th  of  May,  perished  of 
marasmus. 

On  examining  the  body,  after  death,  there  were  found  congestions 
with  sanguineous  exhalation  in  the  small  intestines ;  an  intense  red- 
ness, with  tumefaction  and  friability  of  the  mucous  membrane  of  the 
ileo-cecal  region  and  commencement  of  the  colon,  and  finally  a  pas- 
sive congestion  of  the  cerebro-spinal  apparatus.  The  organs  of 
respiration  were  healthy. 

M.  Rayer  has  given  some  analogous  cases  of  erythema,  in 
which  emollient  lotions  were  successful  in  treating  it  in  children 
at  the  breast.* 

It  sometimes  happens,  without  any  exterior  appreciable  cause, 
that  erythema  spreads  over  different  parts  of  the  body,  under  the 
form  of  irregular  patches,  leaving  intervals  between  them  ;  with- 
out doubt  these  are  what  Bateman  has  described  under  the  name 
of  erythema  marginatum.  According  to  the  English  patholo- 
gists, this  variety  co-exists  ordinarily  with  an  internal  affection, 
and  may  be  accompanied  with  fever  ;  I  have  observed  one  case 
of  this  kind,  which  will  be  noticed  hereafter. 

The  erythema  occurring  on  one  of  the  cheeks  at  the  time  of 
the  appearance  of  the  teeth,  about  the  umbilicus  when  the  cord 
separates,  over  the  two  internal  malleoli  when  the  feet  of  the  in- 
fant are  compressed,  hardly  deserve  our  attention. 

I  believe  I  ought  to  consider  as  a  case  of  erythema  nodosum, 
of  Bateman,  an  affection  of  the  skin  which  I  observed  in  an  in- 
fant, the  subject  of  the  following  case. 

CASE  V. — \Muguety  erythema  nodosum. — Marie  Mosieux,  aged 
thirteen  days,  of  a  medium  strength,  crying  but  little,  respiring  well, 

*  Rayer,  vol.  i.,  p.  104. 

t  Muguet,  a  variety  of  thrush.     Seep.  1 04. 


ON    THE    DISEASES    OP   INFANTS.  97 

with  several  spots  of  muguet  on  the  buccal  mucous  membrane,  which 
was  slightly  tumefied  and  of  a  very  intense  redness,  entered 
the  infirmary  on  the  12th  of  January,  1826.  {Barley,  gum  syrup, 
emoll.  garg.,  abstinence  from  the  breast.)  On  the  following  day 
the  muguet  had  made  some  progress ;  and  on  the  16th,  at  the  inferior 
and  internal  part  of  the  legs,  there  appeared  irregular  red  patches, 
slightly  elevated,  and  hard  to  the  touch,  three  or  four  lines  in  breadth. 
They  appeared  to  be  painful,  for  the  child  cried  on  their  being  rubbed 
with  the  finger ;  the  limbs  were  enveloped  in  compresses,  wetted 
with  a  decoction  of  marshmallows.  On  the  18th  they  had  still  in- 
creased, the  skin  on  one  was  excoriated  ;  on  the  20th,  resolution  had 
commenced,  but  the  left  limb  still  remained  hard  and  swelled.  From 
the  20th  to  the  25th,  a  great  change  had  taken  place  in  the  condition 
of  the  child  ;  the  muguet  had  disappeared,  and  there  only  existed  a 
violet  redness  of  the  legs,  which  however  was  not  of  much  hard- 
ness, and  on  the  third  of  February  the  child  was  returned  to  her 
nurse. 

This  erythema  must  not  be  confounded  with  a  hardening  of 
the  cellular  tissue,  the  history  of  which  will  be  given  hereafter; 
it  appears  to  exhibit  a  great  analogy  to  that  which  Bateman  has 
observed  in  the  legs  of  old  females.  With  respect  to  this,  and 
many  others,  we  meet  with  striking  analogies  between  the  dis- 
eases of  the  two  extremes  of  life. 

For  the  present,  we  have  only  been  considering  acute  erythe- 
ma ;  as  to  the  varieties  of  papular  and  tubercular  erythema,  they 
appear  to  relate  to  those  affections  which  we  have  just  consider- 
ed. I  have  not  had  an  opportunity  of  observing,  in  sucking 
children,  the  chronic  erythema  of  which  Rayer  has  given  some 
examples,  and  which  has  been  described  by  Alibert  under  the 
name  of  dartre  erythemoide.  We  shall  see  in  the  great  number 
of  cutaneous  diseases,  erythematic  inflammation  precede,  accom- 
pany, and  follow,  the  development  of  various  species  of  phleg- 
masise. 

The  erythematic  redness  which  is  developed  in  the  neighbor- 
hood of  the  genitals  in  new-born  children,  should  be  examined 
with  close  attention  ;  and  when  they  exhibit  a  red  coppery  color, 
and  resist  the  continued  applications  necessary  for  the  treatment 
of  ordinary  cutaneous  affections,  and  when  the  surrounding  cel- 
lular tissue  becomes  engorged,  it  will  be  necessary  to  obtain  a 

13 


98  ON   THE  DISEASES   OF    INFANTS. 

more  exact  information  as  to  the  health  of  the  parents,  and  to  be 
assured  whether  or  not  this  erythema  be  not  a  syphihtic  affection. 


ERYSIPELAS. 


Erysipelas  simplex^ 

"  miliaris, 

"  phlyctenoides, 

"  eraticum^ 

"  phlegmonodes, 

"  mdematodes, 

"  capitis^ — thoracis^ — membrorum, 

"  umbilici. 

It  is  well  known  that  in  adults,  erysipelas  is  usually  connected 
with  some  affection  of  the  digestive  organs,  the  functions  of  which 
are  disturbed  either  before  or  after  the  development  of  the  cuta- 
neous disease,  and  that  some  authors  regard  it  as  a  symptom  of 
gastric  disorder,  or  of  gastritis.  The  history  of  erysipelas  in 
young  children  is,  in  this  respect,  somewhat  different.  In  the 
first  place,  it  is  to  be  remarked,  that  of  all  the  cutaneous  phleg- 
masise,  it  is  the  one  which  attacks  the  most  frequently,  because, 
without  doubt,  in  an  infant  recently  born,  the  sanguineous  con- 
gestion of  the  integuments  is  a  predisposing  cause  of  this  inflam- 
mation, and  that  the  irritability  of  the  skin,  recently  deprived  of 
its  epidermis  and  exposed  to  the  contact  of  the  alvine  excretions, 
renders  it  more  liable  to  become  the  seat  of  erysipelas,  which  fre- 
quently succeeds  to  the  erythema  of  which  we  have  been 
speaking. 

During  the  year  1826,  I  observed  in  the  Hospice  des  Enfans 
Trouves,  thirty  cases  of  erysipelas ;  sixteen  of  them  were  sim- 
ple ;  three  cedematous ;  six  phlyctenoid ;  four  phlegmonous ; 
and  only  one  of  the  miliary  form.  In  two  the  face  was  affected  ; 
sixteen,  the  trunk;  and  twelve,  the  limbs.  Erysipelas  of  the 
trunk  and  limbs  then,  appears  to  be  of  more  frequent  occurrence 
than  that  of  the  face. 

The  ages  of  these  thirty  children  varied  from  one  day  to  a 
year  ;  but  it  should  be  noted,  that  there  were  eighteen  below  the 
age  of  six  months  ;  four  between  six  and  eight  months  ;  and  two 
from  eight  months  to  a  year  ;  but  this  proportion  will  not  admit 


ON    THE    DISEASES    OF    INFANTS.  99 

of  extensive  application,  because  children  below  six  months  are 
more  numerous  at  the  Hospice  des  Enfans  Trouves  than  those 
of  more  advanced  age. 

Eight  of  these  infants  were  affected  with  erysipelas  of  the  su- 
perior extremities,  and  of  the  parietes  of  the  thorax,  foUowrno- 
vaccination,  and  during  the  eruption  of  the  pustule. 

In  the  thirty  cases  just  mentioned,  sixteen  were  fatal,  either 
from  the  simple  disease,  or  from  its  compHcation ;  and  among 
these  sixteen,  there  were  six  simple,  two  oedematous,  four  phlyc- 
tenoid,  three  phlegmonous,  and  one  mihary. 

One  case  of  erysipelas  of  the  face  was  followed  by  gangrene  of 
the  mouth,  terminating  in  the  death  of  the  child,  but  fifteen  days 
old  ;  another  case  of  erysipelas  of  the  face  did  not  give  rise  to  any 
unfavorable  symptom.  I  scarcely  remarked  any  gastric  symp- 
toms in  these  cases  of  erysipelas ;  but  there  existed  symptoms  of 
enteritis  more  or  less  violent,  acceleration  of  the  pulse,  dryness 
and  heat  of  the  skin,  and  rapid  emaciation  ;  the  frequency  and 
nature  of  the  cries  of  the  child,  together  with  the  expression  of 
the  face,  usually  indicate  suffering. 

Upon  examining  the  bodies  of  sixteen  children  that  died.  I 
found  in  two,  gastro-enteritis  ;  in  ten,  enteritis  :  in  three,  pneumo- 
nia, complicated  with  enteritis  and  cerebral  congestion  ;  and  in 
one,  pleuro-pneumonia. 

Of  the  four  cases  of  phlegmonous  erysipelas,  it  was  situated  ai 
one,  around  the  umbilicus  and  other  parts  of  the  parietes  of  the 
abdomen ;  in  another,  on  the  left  side  of  the  chest ;  in  a  third,  on 
the  hip  and  superior  part  of  the  right  thigh.  The  patient  died 
after  a  very  extended  disorganization  and  suppuration  of  the  sub- 
cutaneous cellular  tissue  of  this  region;  finally,  the  fourth  was 
affected  on  the  right  leg.  In  four  cases  of  phlyctenoid  er^/^sipe- 
las,  the  disease  appeared  on  the  abdomen  ;  in  the  remaining  two, 
on  the  superior  part  of  the  thighs.  The  miliary  erysipelas  spread 
over  almost  every  part  of  the  body. 

In  no  instance,  in  the  rapid  disappearance  of  the  disorder,  was 
it  followed  by  any  serious  metastasis,  as  is  observed  in  adults. 
Yet  I  believe  this  pathological  phenomenon  may  occur  in 
children. 

Hoffman,  and  after  him.  Underwood,  MM.  Gardien,  and  Ca- 
puron.  have  directed  their  attention  particularly  to  erysipelas  of 


100  ON    THE    DISEASES    OP    INFANTS. 

children.  Underwood  has  described,  under  the  same  name, 
gangrenous  inflammation  of  the  extremities ;  this,  I  believe,  is 
incorrect.  I  will  hereafter  recur  to  this  affection,  when  consider- 
ing the  gangrenous  inflammations  of  the  skin. 

Prom  the  preceding  considerations  and  observations,  it  results 
that  erysipelas,  in  sucking  children,  is  remarkable  for  the  follow- 
ing characters :  1st.  It  is  frequent  at  an  early  age  by  reason  of 
the  sanguineous  congestion  of  the  integuments  at  this  period  of 
Ufe ;  2dly.  It  is  of  more  frequent  occurrence  on  the  abdomen, 
thorax,  and  limbs,  than  on  the  face  or  head.  It  may  terminate 
either  by  resolution,  epidermic  desquamation,  or  by  suppuration 
of  the  subcutaneous  cellular  tissue.  It  is  less  often  accompanied 
by  gastric  symptoms  than  when  it  occurs  in  adults,  but  is  usually 
attended  with  symptoms  of  enteritis  ;  lastly,  it  almost  always 
produces  an  acceleration  of  pulse,  heat  and  dryness  of  the  skin, 
together  with  pain  and  wakefulness.  The  duration  is  from  six 
to  twelve  days.  It  varies  from  a  simple  erythematic  redness  to 
that  of  considerable  tumefaction,  hard  to  the  touch,  of  an  intense 
redness,  and  sometimes  of  a  violet  color. 

The  treatment  should  vary  according  to  the  complications. 
Emollient  applications  ought  to  be  made  to  the  inflamed  integu- 
ments, particularly  when  the  erysipelas  has  a  tendency  to  ter- 
minate in  suppuration,  and  also  to  prevent  the  formation  of  sinus- 
es under  the  skin,  which  follow  suppuration  of  the  cehtilar  tis- 
sue. The  cnteritic  or  pneumonic  symptoms  which  supervene, 
should  be  met  by  the  administration  of  mucilaginous  drinks,  with 
but  little  nourishment.  The  external  causes  which  produce\or 
continue  the  irritation  of  the  skin,  should  be  removed  ;  such  \s 
the  contact  of  foecal  matter,  clothes  either  too  hot,  rough,  or 
tight.  If  the  affection  be  simple  and  superficial,  there  will 
be  no  occasion  for  any  other  than  topical  applications :  an  atten- 
tion to  diet  and  the  use  of  emollient  drinks,  is  all  that  is  necessary ; 
but  should  it  not  yield  to  these  means,  recourse  must  be  had  to 
slight  scarifications  and  local  bleeding  at  some  distance  from  the 
limits  of  the  inflammation;  yet  we  ought  to  be  careful  about  the 
extent  to  which  we  carry  blood-letting  in  children.  We  will  re- 
turn however  to  the  consideration  of  this  subject  in  another  place. 
Local  or  general  bathing  ought  not  to  be  neglected,  and  in  the 


ON    THE    DISEASES    OF    INFANTS.  101 

last  place,  we  should  apply  blisters  on  the  inflamed  part,  as  M. 
Dupuytren  has  recommended  in  adults. 

It  is  important  to  remove  the  idea  foulness  of  the  bowels,  or  of 
gastric  disorder,  for  although  this  complication  is  not  chimerical, 
it  rarely  shows  itself  in  infants  at  the  breast  aifected  with  erysi- 
pelas.* 


RUBEOLA. 

Rubeola  vulgaris, 

a 

sine-catarrho, 

a 

nigra. 

Rubeola,  or  measles,  the  anatomical  characters  of  which  have 
been  already  described,  is  remarkable  for  the  febrile  state  which 
accompanies  it,  and  for  its  complications.  The  most  common 
of  these  are  inflammation  of  the  trachea,  bronchiae,  and  lungs. 
The  digestive  organs  are  less  often  affected  in  the  course  of  this 
eruption,  and  the  cerebro-spinal  apparatus  does  not  become  the 
seat  of  any  derangement,  except  in  certain  individuals.  At  least, 
this  is  the  result  of  the  examination  of  the  nature  and  history  of 
this  epidemic  in  different  countries  by  a  great  number  of  physi- 
cians, particularly  Sydenham,  Mead,  Morton,  Pinel,  and  others. 

Measles  appears  to  be  more  common  after,  than  before  first 
dentition  ]  for  at  the  Hospice  des  Enfans  Trouves,  those  above 
the  age  of  eight,  or  nine  months,  are  those  more  affected  with  the 
disease.  M.  Baron  has,  for  several  years,  remarked  this ;  and 
during  the  year  1826,  in  six  children  attacked  with  it,  there  were 
four  above  the  age  of  eight  months.  Three  of  them  died ;  two 
from  acute  hydrocephalus,  and  the  third  from  a  severe  pneumo- 
nia. Tn  general,  M.  Baron  has  remarked,  that  anginose  and 
cerebral  affections,  were  the  most  ordinary  complication  of 
measles  in  children  at  the  breast.  The  symptoms  of  gastro-en- 
teritis  are  always  of  less  importance  when  they  exist,  and  they 
often  do  not  show  themselves  until  the  end  of  the  disease. 

Other  complications  of  measles,  such  as  petechise,  or  different 
kinds  of  papulae,  appear  in  adults.  As  to  its  terminations,  we 
would  observe  that,  in  young  subjects,  the  cutaneous  eruption  is 
very  frequently  followed  by  anasarca  or  desquamation ;  the  for- 

*  See  Appendix,  page  551. 


102  ON     THE    DISEASES    OF    INFANTS. 

mer  termination,  without  doubt,  is  attributable  to  the  Uttle  vital 
reaction,  and  to  the  natural  slowness  of  the  passage  of  the  blood 
in  patients  who  have  been  debilitated  ;  the  latter,  to  the  facility 
with  which  the  epidermis  exfoliates  in  infants. 

The  treatment  of  measles  must  vary  according  to  its  complica- 
tions. It  is  observed  that  these  have  been  different  in  different 
epidemics  ;  from  this,  no  doubt,  arises  the  predilections  of  certain 
authors  for  a  favorite  method  of  treatment.  From  this  cause  it  is 
that  some  are  so  partial  to  emetics.  Thus  Pinel,  who  had  only 
seen  it  prevail  at  the  Salpetriere  in  a  very  mild  form,  has  recom- 
mended the  expectant  method,  whilst  Mead  has  advised  bleeding 
as  a  remedy  of  universal  application. 

If  the  danger  of  measles  is  considered  as  arising  from  the  na- 
ture of  the  complication,  we  should  direct  our  attention  to  this  ac- 
companying disease.  The  treatment  under  these  circumstances, 
will  be  found  in  the  history  of  each  of  the  organs  which  may  be- 
come the  seat  of  these  complications.  I  will,  in  this  place,  con- 
fine myself  to  the  attention  which  the  patient  requires  with  refer- 
ence to  the  cutaneous  eruption. 

The  drinks  which  have  been  recommended  as  suitable  to  favor 
the  development  of  the  eruption,  ought  to  be  administered  with 
great  caution.  In  case  of  metastasis,  the  warm  bath  appears  to 
me  very  proper  to  restore  the  cutaneous  irritation.  Of  this  we 
must  be  very  careful,  should  cerebral  congestion  supervene  in  the 
child.  Emetics,  when  there  is  reason  to  believe  the  existence  of 
gastric  derangement,  and  purgatives,  when  it  is  necessary  to  re- 
lieve the  bowels,  should  be  given  with  much  caution  in  young 
children  in  whom  the  alimentary  canal  is  one  of  the  parts  most 
susceptible  of  irritation.  We  should  also  be  careful  in  the 
use  of  remedies  for  the  relief  of  debility,  to  which  patients  with 
measles  are  sometimes  subject.  We  shall  hereafter  see  what 
lesions  ordinarily  accompany  the  adynamic  condition  of  young 
children ;  and  will  then  understand  how  dangerous  it  might  be 
to  give  cordials  and  antiseptics  in  a  pathological  condition,  as  va- 
riable in  its  causes  as  in  the  interpretations  which  have  been  given 
to  the  term  by  which  it  is  expressed. 

Tonics  are  only  useful  in  a  state  of  extreme  debility  and  ma- 
rasmus, occurring  after  measles,  and  when  they  are  not  contra- 
indicated  by  any  organic  lesion.* 

*  See  Appendix^  page  553. 


ON    THE    DISEASES    OF    INFANTS.  103 


ROSEOLA. 

Roseola  cestiva, 

autumnalis, 

armulata, 

infantilis^ 

variolosa, 

vaccina, 

miliaris. 

Roseola  is  a  very  superficial  inflammation  of  the  skin,  never 
spreading  to  such  an  extent  as  erythema,  very  often  mingled  with 
other  symptoms,  such  as  variola,  vaccinia,  etc.,  and  of  frequent 
occurrence  in  infants.  Its  varieties,  which  refer  more  to  the 
period  of  its  appearance  and  to  the  disposition  of  the  spots,  than 
to  the  difference  in  the  symptoms,  scarcely  deserve  attention. 

I  have  often  seen  it  develop  itself  on  the  surface  of  the  body, 
neck,  and  limbs  of  sucking  children,  as  well  as  of  those  just  born. 
It  appears  to  produce  very  great  irritation  of  the  skin,  for  some 
children  cry  much  when  they  are  attacked  with  it.  Summer  is 
the  season  in  which  it  more  particularly  occurs.  Its  duration  is 
very  variable  ;  and  it  often  consists  of  nothing  more  than  small 
patches  of  a  rosy  color,  irregular  and  smooth,  often  appearing 
and  disappearing  every  moment  of  the  day.  In  the  greatest  num- 
ber of  cases  there  is  neither  fever  nor  any  disorder  in  the  digestive 
functions  ;  and  were  it  not  for  the  cries  and  sleeplessness  of  the 
child,  attention  would  be  scarcely  attracted  to  this  slight  eruption. 
Children  are  more  subject  to  it  at  the  age  of  six  months  to  a  year, 
than  at  an  earlier  period ;  and  it  more  particularly  makes  its  ap- 
pearance about  the  time  of  dentition. 

When  this  disease  is  not  preceded  by  some  other  cutaneous 
affection,  and  no  functional  derangement  accompanies  it,  it  will 
be  sufficient  to  administer  to  the  child  some  mild  anodyne,  such 
as  the  syrup  of  poppies,  in  a  little  sweetened  water,  and  to  use 
ablutions  at  a  low  temperature. 

If  there  exist,  at  the  same  time,  any  cerebral  irritation,  or  any 
affection  of  the  alimentary  canal,  or  of  the  respiratory  apparatus, 
the  physician  should  meet  these  symptoms  with  suitable  means. 


104  ON    THE    DISEASES   OF    INFANTS, 

It  is  particularly  important  to  notice  whether  roseola  be  not  the 
first  appearance  of  a  disease  of  more  importance,  the  characters 
of  which  will  afterwards  more  fully  appear. 

SCARLATINA. 

Scarlatina  simplex, 
"         anginosa, 
'*         maligna. 

Scarlatina  is  always  accompanied  with  violent  fever,  very  often 
with  angina  or  ophthalmia,  and  sometimes  with  pneumonia,  gas- 
tro-enteritis,  or  encephalitis. 

Of  all  the  complications,  that  of  the  throat  is  the  most  frequent 
and  serious.  Inflammation  of  the  larynx  or  tonsils  exists  in  a 
greater  or  less  degree  in  almost  every  case  of  scarlatina,  either  at 
the  commencement  or  in  the  course  of  the  disease.  It  would 
s§em  that  the  other  complications  are  only  observed  in  such  as 
are  exposed,  by  a  particular  predisposition,  to  inflammations  of 
the  encephalon  or  of  the  alimentary  canal. 

Scarlatina  prevails  more  particularly  during  second  infancy 
and  in  youth,  than  during  the  period  of  sucking.  This  disease 
often  appears  at  the  Hospice  des  Enfans-Malade,  while  it  is  scarce- 
ly seen  in  the  course  of  a  year  at  the  Hospice  des  Enfans  Trou- 
ves  •,  and  in  1826,  when  scarlet  fever  existed  in  this  hospital, 
three  children,  aged  from  one  year  to  fifteen  months,  were  attacked 
with  it,  while  none  of  a  more  tender  age  were  aflfected.  M,  Baron 
has,  for  a  long  time,  made  the  same  remark,  the  correctness  of 
which  is  evident  when  it  is  considered  that  all  the  epidemics  of 
scarlatina  prevail  among  children  collected  in  boarding-schools 
or  hospitals. 

Be  this  as  it  may,  I  admit  that  scarlatina  does  not  affect 
children  in  the  first  infancy  in  the  same  manner  as  it  attacks 
those  of  more  advanced  age.  It  appears  first  in  a  simple  form, 
that  is  to  say,  with  a  slight  febrile  action,  without  apparent  lesion 
of  any  organ  ;  secondly,  with  affections  of  the  throat,  either  sim- 
ple, croupy,  or  gangrenous,  the  most  distressing  and  the  most 
common  complications  of  the  disease.  Finally,  this  eruption 
may  assume  a  fatal  character  by  the  simultaneous  development 
of  menengitis,  of  encephalitis,  or  gastro-enteritis,  giving  rise  to  a 


ON   THE    DISEASES    OP    INFANTS.  105 

serious  train  of  symptoms,  constituting  the  adynamic  fever  of 
authors. 

The  treatment  of  scarlatina  must  vary  according  to  the  simple 
or  complicated  condition  in  which  it  exists. 

When  it  is  simple,  it  will  only  be  necessary  to  moderate  the 
febrile  action  and  cutaneous  irritation,  by  attention  to  diet  and 
the  use  of  emollient  drinks  at  first,  afterwards  slightly  acidulated. 
The  patient  ought  to  be  removed,  that  no  communication  may 
exist  between  him  and  other  children,  for  this  phlegmasia  is  al- 
most always  contagious.  If  the  redness  of  the  skin,  together 
with  the  reiterated  cries  of  the  child,  indicate  excessive  irritation 
of  the  integuments,  it  should  be  tranquillized  by  emollient  lotionsy 
slightly  narcotized,  applied  to  the  body  and  limbs,  such  as  the 
decoction  of  marshmallows  and  poppy  heads ;  but  not  by  the 
internal  administration  of  opium,  as  recommended  by  Sydenham, 
except  with  the  greatest  caution,  under  the  apprehension  of  irri- 
tating the  brain,  the  inflammation  of  which  is  often  a  compli- 
cation of  scarlatina. 

Dr.  Currie,  of  Liverpool,  has  spoken  in  high  terms  of  the  ex- 
ternal application  of  cold  water  in  the  treatment  of  some  acute 
diseases,  and  Bateman  has  recommended  it  in  the  treatment  of 
scarlatina,  to  produce  a  favorable  diaphoresis. 

This  remedy,  known  from  the  highest  antiquity — since  it  ap- 
pears to  have  been  used  by  Antonius  Musa,  physician  to  Augus- 
tus— ought  only  to  be  employed  by  the  most  experienced  and  the 
most  prudent ;  if  the  traditions  accredited  by  M.  Leclerc  are  to 
be  believed,  Musa  himself  appears  to  have  suspected  that  by  this 
means  the  premature  death  of  the  young  Marcellus  was  hastened, 
the  name  of  whose  disease  has  not  come  down  to  us ;  but  the 
remembrance  of  this  fact,  if  it  be  true,  should  not  hinder  our 
using  this  agent  with  the  precautions  mentioned  by  Bateman.  If 
we  are  unable  to  throw  cold  water  over  the  body  of  the  patient 
when  the  skin  is  dry  and  hot,  for  fear  of  terrifying  the  mother 
or  nurse,  we  ought  at  least  to  sponge  the  face,  neck,  arms,  and 
body,  with  cold  vinegar  and  water. 

The  practitioner  ought  to  abandon  the  old  routine  of  envelop- 
ing the  patient  in  a  triple  covering  of  bed  clothes  ;  but  direct  the 
air  of  the  bedroom  to  be  renewed,  carefully  avoiding  the  expo- 
sure of  the  patient  to  sudden  changes  of  temperature. 

14 


106  ON  THE   DISEASES  OP   INFANTS. 

The  complications  of  scarlatina,  such  as  ophthalmia,  encephali- 
tis, pleuro-pneumonia,  angina,  enteritis,  and  the  symptoms  known 
under  the  vague  title  of  putrid,  demand  particular  notice,  and 
will  be  duly  considered  in  the  diiferent  parts  of  this  work  devoted 
to  the  history  of  these  diseases. 

After  the  disappearance  of  febrile  symptoms,  redness  of  the  in- 
teguments, and  the  symptoms  complicating  this  disease,  the  phy- 
sician will  still  have  to  encounter  anasarca,  a  sequela  of  very 
common  occurrence  in  scarlatina. 

M.  Viesseux,  of  Geneva,  has-  recommended  that  great  care  be 
also  used  in  preventing  children  from  being  exposed  to  the  cold 
air  for  some  days,  or  even  weeks,  during  their  convalescence, 
because  he  attributes  the  infiltration  of  the  cellular  tissue  to  the 
action  of  this  external  agent.  Sydenham  has  advised  laxatives 
after  the  period  of  desquamation.  I  think  they  are  useful  if  there 
exist  no  symptoms  of  gastro-enteritis ;  they  may  be  followed  by 
mild  tonics,  such  as  a  teaspoonful  of  Malaga  wine,  or  wine  of 
Cinchona,  particularly  where  the  circulation  is  habitually  slow.  Fi- 
nally, many  physicians  recommend  dry  or  aromatic  frictions,  fumi- 
gations slightly  stimulating,  tepid  or  stimulatingbaths.  In  addition 
to  these,  I  would  recommend  enveloping  the  child  in  fine  soft  flan- 
nel, applied  next  to  the  skin.  These  means,  together  with  exer- 
cise and  moderate  nourishment,  should  be  pursued  or  suspended, 
according  to  the  particular  indications  ;  and,  if  properly  directed, 
will  serve  a  much  better  purpose  than  stimulants,  solvents,  de- 
obstruents,  drastics,  and  other  violent  remedies,  so  often  praised 
in  the  treatment  of  dropsy.* 

URTICARIA. 

Urticaria  fehrilis, 
"         evanida, 
"        perstanSj 
"        conferta, 
"        suhcutanea. 
"        tuberosa. 

All  these  varieties  of  urticaria  pointed  out  by  Bateman  and 

*  See  Appendix,  page  555. 


ON  THE    DISEASES    OF    INFANTS.  107 

Frank,  depend  ordinarily  on  the  varieties  of  form  and  complica- 
tion of  the  eruption.  I  think  it  most  important  to  note  the  three 
following  varieties  :  First,  urticaria  arising  spontaneously  with- 
out any  febrile  action,  with  nothing  but  an  itching  sensation  in 
the  part  of  the  integuments  accompanied  by  the  eruption  ;  se- 
condly, urticaria  arising  from  indigestion  in  the  stomach  of  food 
badly  prepared,  or  composed  of  principles  obnoxious  to  the  sys- 
tem, such  as  muscles,  under  certain  circumstances  ;  lastly,  when 
accompanied  by  fever,  more  or  less  violent,  continued  intermit- 
tent, or  remittent ;  the  eruption  then  is  moderate  or  severe,  ap- 
pears and  disappears,  according  to  the  remissions  or  intermissions 
of  the  fever. 

I  have  sometimes  observed  urticaria  without  fever  in  infants  at 
the  breast,  appear  and  disappear  several  times  in  the  day,  with- 
out giving  rise  to  any  unfavorable  symptom.  Yet  the  crying 
and  restlessness  of  the  child  led  me  to  believe  that  a  great  itch- 
ing must  have  been  experienced.  Underwood,  who  has  spoken 
of  this  mild  variety  of  urticaria,  says  that  it  disappears  ordinarily 
in  a  very  short  time. 

Thus,  then,  urticaria  is,  in  infants  generally,  a  mild  disease, 
and  it  is  commonly  in  adults  that  it  is  accompanied  with  febrile 
symptoms,  and  a  greater  or  less  disturbance  of  the  digestive  or- 
gans. 

If  it  show  itself  in  young  infants  with  but  little  intensity,  at- 
tention to  diet  and  the  ordinary  rules  of  hygiene,  will  be  all  that 
is  necessary.  In  case  of  a  long  continuance  of  this  disease,  Un- 
derwood advises  the  use  of  a  few  grains  of  the  compound  pow- 
der of  contrayerva,  or  of  absorbent  powder  with  the  addition 
of  a  few  drops  of  ammoniated  alcohol.  But  of  what  utility  is 
this  treatment  ?  Is  there  any  thing  more  vague  than  this  ad- 
vice? .  Would  it  not  be  better  to  seek  for  some  functional 
or  organic  lesion,  on  which  the  continuance  and  obstinacy  of 
the  disease  may  depend,  and  direct  the  treatment  accordingly  ? 

Should  it  proceed  from  indigestion,  or  from  any  kind  of  poi- 
son, it  would  then  be  proper  to  give  a  mild  emetic  to  relieve  the 
stomach  from  the  irritating  substance  which  it  contains  ;  and  if 
the  cutaneous  eruption  appear  on  the  access  of  an  intermittent 
fever,  the  administration  of  a  febrifuge  is  very  naturally  indi- 
cated. 


108  ON    THE    DISEASES    OF    INFANTS. 


BLISTERS. 


It  is  unnecessary  to  stop  and  describe  at  length,  this  artificial 
inflammation  of  the  skin,  which,  as  we  shall  hereafter  see,  may 
either  be  of  great  utility,  or  give  rise  to  the  most  serious  symp- 
toms in  children,  according  as  they  may  be  well  or  badly  employ- 
ed. The  effect  of  blisters  in  exhausting  the  patient  by  the  secre- 
tion which  they  produce,  should  never  be  lost  sight  of,  as  has 
been  remarked  long  since  by  Baglivi,  Pinel,  Corvisart,  and 
Broussais.  This  remark  is  particularly  applicable  to  diseases  of 
children. 


ESSERA. 


When  care  is  used  in  clothing  infants  properly,  that  is  to  say 
without  bandaging  them  in  the  cruel  manner  formerly  practised, 
they  will  rarely  have  this  affection,  for  it  is  always  the  result  of 
mechanical  pressure  on  the  part. 

PEMPHIGUS  AND    POMPHOLIX. 

Pemphigus,  for  the  first  time  described  by  Sauvage,  and  united 
by  Bateman  to  what  he  calls  pompholix,  an  eruption,  the  ana- 
tomical characters  of  which  differ  from  the  former  only  in  a 
slight  degree,  has,  for  a  long  time,  been  considered  as  essentially 
united  to  a  species  of  fevers  denominated  vesicular.  But  since 
the  publication  of  the  excellent  work  of  Gilibert,  Pinel  and  other 
pathologists  have  denominated  pemphigus,  the  cutaneous  affec- 
tion characterized  by  the  development  of  erythematic  patches 
over  different  parts  of  the  body,  on  the  surface  of  which  bullae 
arise,  which  soon  break,  leaving  a  viscid  yellowish  fluid.  This 
fluid  concretes,  and  forms  on  the  ulcerated  surface  a  slightly  pro- 
jecting scab,  often  granulated  and  yellow,  like  honey,  or  rather 
approaching  to  a  fawn  color. 

This  eruption  is  sometimes  accompanied  with  fever,  and  is 
sometimes  apyrectic.  Its  duration  may  be  either  for  a  short  or 
for  a  long  time  ;  hence  the  distinction  between  acute  and  chronic 
pemphigus — a  very  correct  distinction,  and  of  great  practical 
utility. 

Acute,  apyrectic  pemphigus,  is  very  common  among  children 


ON   THE    DISEASES   OF    INFANTS.  109 

at  the  breast ;  the  febrile  variety  is  more  rare ;  chronic  pemphi- 
gus is  sometimes  met  with.  Willan  has  noticed  in  infants,  pem- 
phigus to  which  he  has  given  the  name  of  infantilis.  I  have 
seen  the  acute  form  of  the  disease  several  times  at  the  Hospice 
des  Enfans  Trouves,  and  the  following  case  appears  to  present, 
with  great  variety,  the  characters  of  this  affection  when  occur- 
ing  in  sucking  infants. 

CASE  VI. — Acute  pemphigus,  mugueU  Enteritis, — Caroline  Per- 
neau,  aged  four  months  and  a  half,  had  been,  from  birth,  in  charge 
of  the  nurses  at  the  hospital;  on  the  12th  of  January,  1826,  was  at- 
tacked with  diarrhoea ;  she  became  pale  ;  could  not  sleep,  and  took 
the  breast  with  less  eagerness.  She  entered  the  infirmary  on  the 
15th  of  February,  and  exhibited  the  following  appearance:  strength 
moderate  ;  face  pale  and  a  little  shrunk  ;  but  the  body  and  limbs  still 
preserved  their  firmness  and  vermillion  hue  ;  she  cried  but  little  ;  the 
base  of  the  tongue  was  covered  with  muguet ;  the  buccal  mucous  mem- 
brane was  of  an  intense  red ;  the  pulse  beat  about  ninety ;  urine 
abundant ;  was  affected  with  a  diarrhoea  of  a  yellow  color  ;  [guinvied 
rice  water,  starch  injections,  abstinence  from  the  breast.)  On  the 
following  day  there  appeared  on  the  cheeks  a  few  small,  slightly 
transparent  bullae,  some  of  the  size  of  a  hemp-seed,  others  of  that 
of  a  lentil,  and  all  of  them  arising  in  the  midst  of  erythematic  spots. 
The  appearance  of  these  bullae  did  not  augment  the  distress  of  the 
child,  who  neither  cried  nor  manifested  any  distress,  notwithstanding 
the  pulse  was  accelerated  and  the  skin  dry  and  burning.  On  the 
19th,  the  bullae  on  the  face  had  disappeared,  or  had  been  torn  by  the 
fingers  of  the  child  ;  in  their  place,  was  a  yellow  superficial  scab, 
surrounded  by  a  red  mark  or  circle,  without  tumefaction.  The  di- 
arrhoea continued  ;  the  muguet  had  spread  over  the  rest  of  the  buccal 
membrane;  the  child  became  much  emaciated;  pulse  from  110  to 
115.  On  the  20th,  other  bullae  appeared  on  the  neck  and  upper  part 
of  the  chest;  but  they  were  smaller  than  those  on  the  face,  the  scabs 
of  which  had  begun  to  fall,  leaving  beneath  them  a  red  mark.  On 
the  22d,  the  bullae  on  the  neck  had  undergone  the  same  change  in 
the  formation  of  scabs  as  those  on  the  face,  which  were,  for  a  se- 
cond time,  covered  with  very  thin  yellow  concretions.  On  the  25th 
the  child  vomited  her  drinks  ;  the  paleness  and  emaciation  increas- 
ed ;  the  pulse  was  a  little  more  frequent.  From  the  25th  to  the  30th, 
she  gradually  sunk,  other  bullae  showing  themselves  successively  on 


110    .  ON   THE    DISEASES    OF    INFANTS. 

the  parietes  of  the  thorax.  On  examining  the  body,  the  brain  was 
found  a  little  injected  ;  the  tongue  and  velum  covered  with  muguet ; 
oesophagus  violet-colored;  stomach  covered  with  red  spots;  the 
small  intestines  healthy;  and  on  the  internal  membrane  of  the  colon 
appeared  striae,  red  patches,  and  a  very  evident  tumefaction ;  the 
liver  was  healthy  ;  the  lungs  gorged  with  blood — the  right  congest- 
ed at  the  summit ;  the  heart  also  was  filled  with  blood. 

This  eruption  appeared  to  me  to  present  all  the  characters  of 
pemphigus,  or  of  pompholix ;  and  it  was  here  complicated  with 
colitis  and  muguet. 

It  appears  as  if  this  cutaneous  inflammation  may  be  developed 
without  this  complication,  for  Willan  has  described,  under  the 
name  of  pomj^holis  benignus,  the  successive  appearance  of  trans 
parent  bullae,  about  the  size  of  a  pea,  and  sometimes  of  a  hazel- 
nut, on  the  face,  neck,  and  limbs  of  young  children,  during  den- 
tition, and  of  only  a  few  days'  duration. 

When  the  pemphigus  is  simple,  bathing,  together  with  emol- 
lient lotions  and  mild  regimen,  will  be  sufficient  for  its  treatment; 
but  if  it  be  complicated  with  fever  or  enteritis,  it  requires  close 
attention  on  the  part  of  the  physician.  Lastly,  if  pemphigus  be- 
come chronic,  great  difficulty  will  then  be  experienced  in  its 
treatment;  for  children  affected  with  chronic  pemphigus  are 
usually  reduced  to  marasmus,  and  present  but  little  chance  for 
the  action  of  remedies  suitable  for  the  management  of  inflamma- 
tion. Willan  and  Bateman  have,  in  these  cases,  recommended 
tonics  and  nutritive  diet ;  and  cinchona  has  been  used  internally, 
and  also  externally,  in  the  form  of  a  lotion  to  the  skin,  by  some 
physicians ;  baths,  not  hot,  as  Willan  advises,  but  at  a  low  tem- 
perature, will  be  found  useful  remedies  ;  ablutions  with  vegeto- 
mineral  water  ;  frictions  with  oxygenated  pomatum,  {unguentwn 
acidi  nitrosi  E.,)  in  the  parts  where  the  ulcerated  derma  is  con- 
tinually covered  with  new  scabs  ;  a  change  of  nurse,  of  food,  and 
of  climate  ;  daily  exposure  to  the  external  air,  but  only  for  a  short 
time  each  day  ;  the  selection  of  good  milk  when  the  child  is  arti- 
ficially nourished,  are  the  general  indications  for  the  treatment 
of  this  disease  in  young  infants.  Pinel  has  advised  to  abstain 
from  all  topical  applications,  and  not  interfere  with  the  progress 
of  the  disease.  This  is,  no  doubt,  proper  in  the  case  of  acute 
pemphigus,  accompanied  by  fever,  of  which  it  is,  as  we  may  say, 


ON   THE    DISEASES    OF    INFANTS.  Ill 

but  a  symptom  ;  but  is  it  wise  to  remain  a  tranquil  spectator  of 
the  progress  of  the  phlyctense  and  ulcerations,  which  in  chronic 
pemphigus  undermine,  by  pain  and  exhaustion,  the  constitution, 
and  shorten  the  days  of  the  little  patient  ?     I  think  not. 

RUPIA. 

Rupia  simplex^ 
•'      prominens, 
"       escharotica. 

Rupia  is  met  with  in  scrofulous  children,  who  are  badly  nour- 
ished and  debilitated.  Certain  atonic  ulcers  of  the  legs  which 
follow  bullae,  the  development  of  which  has  sometimes  escaped 
the  notice  of  the  physicians,  are  no  other  than  true  rupia,  recog- 
nizable particularly  by  the  form  and  color  of  the  scabs  that  are 
continually  rising  to  their  surface. 

Bateman  notices  three  varieties  of  rupia :  small  phlyctense, 
which  are  filled  with  a  clear  lymph,  situated  on  different  parts 
of  the  body,  where,  breaking  and  spreading,  they  produce  small 
black  scabs,  constituting  that  form  of  the  disease  denominated 
rupia  simplex.  If  the  scabs  are  raised,  conical,  striated,  or  ru- 
gose, it  then  takes  the  name  of  prominens ;  and  that  of  escha- 
rotica^ when  the  vesicles,  which  show  themselves,  in  general, 
on  the  loins,  thighs,  and  legs,  contain  a  sanious  or  corrosive 
fluid,  and,  terminating  by  sloughs,  produce,  on  being  detached, 
deep  ulcerations.  This  last  variety,  according  to  Bateman,  is 
frequently  observed  in  those  infants  at  the  breast  previously 
much  reduced  by  sickness,  badly  nourished,  or  badly  clothed. 

I  have  not  had  an  opportunity  of  seeing  rupia  escharotica  at  the 
Hospice  des  Enfans  Trouves,  where  infants  are  often  found  in 
the  condition  described  by  the  English  pathologist ;  but  I  have 
often  seen  on  the  legs  and  thighs  of  children  reduced  to  maras- 
mus, phlyctena?  or  ulcerations  afterwards  covered  with  solid 
black  scabs,  presenting  the  characters  which  Bateman  calls  rupia 
simplex. 

The  scabs  should  be  removed  by  the  aid  of  cataplasms, 
and  the  ulcerations  beneath  dressed  with  perforated  linen  spread 
over  with  cerate  of  acetate  of  lead ;  the  ulcerated  surfaces  ought 
also  to  be  washed  from  time  to  time  with  wine  and  water,  or  a 
weak  decoction  of  cinchona  or  alum-water ;  powdered  alum,  or 


112  ON  THE  DISEASES  OP   INFANTS. 

cream-of-tartar  may  be  sprinkled  over  the  ulcer ;  at  the  same 
time  administering  tonics  internally,  such  as  a  weak  decoction  of 
wild  cichory,  hops,  cresses,  or  saponaria.  The  strength  of  the 
patient  should  also  be  promoted  by  allowing  aliments  that  abound 
in  nutritive  principles.  In  every  case,  the  condition  of  the  ali- 
mentary canal  ought  to  be  closely  watched. 

ZONA,  OR   ZOSTER. 

This  disease,  although  common  in  adults,  is  rarely  observed 
in  infants  at  the  breast ;  I  have  seen  but  one  instance  of  it  in 
eight  hundred  children  that  were  admitted  into  the  infirmary  du- 
ring the  year  1826. 

This  eruption  is  usually  connected  with  a  more  or  less  marked 
derangement  of  the  functions  of  digestion ;  it  is  almost  always 
preceded  or  accompanied  by  some  degree  of  debility,  and  causes 
much  sickness  and  pain,  particularly  when  the  bullae,  or  the  vesi- 
cles which  are  mingled  with  them,  break ;  they  then  give  rise  to 
superficial  ulcerations,  which  are  soon  covered  with  very  thin  yel- 
low scabs. 

The  treatment  ought  to  consist  of  such  means  as  are  suitable 
for  the  management  of  disordered  digestion.  Topical  applica- 
tions to  the  ulcers  should  be  dispensed  with  altogether,  at  least 
until  the  excessive  pain  demands  the  use  of  emollient  and  anodyne 
cataplasms. 


erp 

►es  phlj/ctoenodesj 

a 

iris, 

ti 

circinatus, 

u 

labialis, 

u 

prceputialiSj 

it 

auricularis. 

Willan,  Bateman,  and  M.  Rayer,  have  described,  under  the 
name  of  herpes,  a  disease  different  from  that  which  bears  this 
name  in  the  works  of  MM.  Lorry  and  Alibert.  Every  body 
has  observed  these  little  vesicles,  which  appear  on  the  lips  of 
those  who  have  recently  experienced  an  attack  of  fever,  at  first 
vesicular,  then  exhibiting  an  excoriated  surface,  covered  with  a 
yellowish  scab ;  this  is  the  eruption  designated  by  the  English 


ON   THE    DISEASES   OF    INFANTS.  113 

pathologists  under  the  name  of  herpes  labialis,  and  will  give  an 
idea  of  the  genus  herpes. 

The  general  symptoms,  usually  accompanying  herpes,  are  of 
little  moment  j  it  is  not  a  disease  peculiar  to  infancy ;  yet  some 
of  the  varieties  may  be  met  with  in  young  infants. 

The  species  of  herpes  are  established— 1st,  According  to  the  form 
of  the  groups  or  vesicles :  Heripes  phlyctosnodesy  globular  and  trans- 
parent vesicles,  about  the  size  of  a  millet  seed,  appearing  in  dif- 
ferent parts  of  the  body,  generally  preceded  by  red  spots,  more 
or  less  extended,  and  attended  with  a  violent  itching.  Herpes 
irisj  vesicles  surrounded  with  concentric  rings  of  various  colors. 
Herpes  circinatuSj  characterized  by  erythematic  spots,  sur- 
rounded by  an  areola  of  vesicles.  2dly,  Others  take  their  names 
from  the  seat  of  the  disease  :  Herpes  labialis,  herpes  prceputia- 
lis  ;  groups  of  small  globular  vesicles,  accompanied  with  pru- 
ritis,  developed  on  the  external  or  internal  surface  of  the  lips  and 
prepuce*  There  are  also  herpes  auricularisj  palpebralis,  vul- 
varis. 

When  herpes  prceputialisy  or  vulvaris,  is  observed  in  young 
infants,  we  should  examine  whether  it  be  of  a  venereal  nature, 
and  notice  particularly  the  form  of  the  vesicles,  the  slight  circle 
that  surrounds  them,  the  color  of  the  scales  which  succeed  them^ 
and  the  effect  of  the  remedies  used. 

The  treatment  of  herpes  ought  to  be  simple,  since  there  are 
scarcely  ever  any  complications  in  this  disease.  Demulcent  or 
slightly  acidulated  drinks  should  be  administered,  and  emollient 
lotions  applied  to  the  part;  or  when  the  scabs  are  constantly  form- 
ing on  the  surface  of  the  superficial  excoriations  which  succeed 
the  vesicles,  the  affected  part  may  be  washed  with  a  weak  solu- 
tion of  alum. 

ECZEMA. 

Eczema  solare, 

"       impetiginodeSy 
"       rubrum, 
"       acutum, 
"       chronicum. 

This  disease  has  been  confounded  with  psora,  and  some  au- 

15 


114  ON    THE    DISEASES    OF    INFANTS. 

thors  have  described  it  under  the  name  of  "  dartre  squameuse 
humide." — (AUbert.) 

The  rounded  vesicles,  surrounded  by  small  red  circles,  which 
characterize  eczema,  show  themselves  in  a  distinct  form  on  the 
face,  limbs,  and  upper  part  of  the  thighs.  They  disappear 
promptly  either  by  absorption,  or  by  having  discharged  the  fluid 
they  contained,  and  which  concretes  in  the  form  of  thin  scabs. 
In  such  a  case,  eczema  may  be  considered  as  acute  ;  it  scarcely 
affects  the  health  of  the  patient,  and  requires  nothing  more  than 
good  nursing,  demulcent  regimen,  and  emollient  baths. 

But  when  it  resists  these  simple  means ;  when,  assuming  a 
chronic  character,  the  vesicles  are  continually  renewed,  or  spread, 
multiply,  and  mingle  together,  producing  an  abundant  secretion, 
and  forming  a  number  of  scabs,  beneath  which  numerous  vesi- 
cles arise  without  cessation  ;  then  emaciation,  pain,  disorder  of 
the  digestive  functions,  and  febrile  reaction  ensue,  seriously  af- 
fecting the  health  of  the  patient,  the  case  then  demands  the 
especial  care  and  attention  of  the  physician. 

In  general,  eczema  may  be  either  acute  or  chronic  ;  and  it  is 
more  frequently  met  with  in  youth  and  adults,  than  among  old 
people  or  infants  at  the  breast.  Yet,  there  is  variety  of  eczema 
often  to  be  seen  among  the  latter;  it  occurs  in  the  scalp,  and  is 
known  by  the  formation  of  small  bluish  vesicles  on  the  head, 
and  upon  discharging  a  fluid  which  quickly  concretes,  produces 
a  disease  somewhat  resembling  tinea. 

I  have  often  noticed  on  different  parts  of  the  trunk  and  limbs 
of  new-born  children,  small  distinct  vesicles,  each  surrounded  by 
a  little  red  circle  ;  they  appear  suddenly,  and  often  end  in  resolu- 
tion; but  sometimes  breaking,  produce  small  superficial  scabs. 
These  vesicles  are  two,  three,  or  four  in  number,  far  removed 
from  each  other  ;  and  are  met  with  indifferently  on  the  face, 
trunk,  and  limbs  ;  and,  except  as  to  their  number,  they  exhibit  the 
strongest  marks  of  eczema.  I  have  no  doubt  of  this  being  a  va- 
riety of  the  disease  now  under  consideration.  I  have  met  with 
it  in  children  scarcely  a  day  old,  and  have  thereby  been  led  to 
believe  that  the  child  has  brought  the  affection  with  it  into  the 
world.  The  sisters  of  the  Hospice  des  Enfans  Trouves,  in  con- 
sequence of  the  dread  which  even  the  shadow  of  a  disease,  if  we 


ON    THE    DISEASES    OF    INFANTS.  115 

may  so  speak,  of  a  venereal  nature  inspires  them,  are  in  the  ha- 
bit of  regarding  these  vesicles  as  venereal  pustules,  and  adopt,  in 
every  instance,  an  anti-syphilitic  treatment.  M.  Baron  does  not 
ordinarily  participate  in  this  fear,  and  I  have  seen  these  vesicles 
disappear  of  themselves  at  the  end  of  a  few  days  after  the  chil- 
dren have  been  in  the  infirmary. 

Mercurial  eczema  may,  without  doubt,  be  developed  in  infants 
nursed  by  women  who  have  used  mercury  internally  or  exter- 
nally ;   but  I  am  not  acquainted  with  any  case  of  this  kind. 

The  treatment  of  chronic  eczema  is  as  difficult  in  its  choice 
and  direction,  as  it  is  uncertain  in  its  results  ;  yet  the  general 
principles  of  treatment  must  be  borne  in  mind.  Thus  we  should 
consider  primarily  of  what  nature  are  the  symptoms  of  reaction: 
what  the  seat  of  the  concomitant  alterations  of  the  cutaneous 
eruption ;  whether  the  obstinacy  with  which  the  vesicles  and 
scabs  are  produced,  be  owing  to  the  peculiar  alteration  of  the 
fluid,  as  was  formerly  taught,  and  as  some  physicians  at  the  pre- 
sent day  believe  ;  or  whether  the  alteration  in  the  cutaneous  se- 
cretion be  the  result  of  a  change  in  the  tissue,  and  in  the  nutri- 
tive activity  of  the  organ  charged  with  this  secretion.  The 
physician  should  always  endeavor  to  modify  the  actual  state  of 
the  constitution  of  the  patient,  that  the  disease  with  which  he  is 
affected  may  be  successfully  treated.  To  accomplish  this  object, 
several  therapeutic  means  have  been  advised.  As  external  ap- 
plications, emollient  baths,  saturnine  lotions,  solution  of  nitrate 
of  silver,  diluted  muriatic  acid,  cataplasms  of  chelidonium  minus, 
sulphurous  vapor  baths,  etc.,  are  recommended. 

As  internal  remedies,  there  have  been  used  the  vegetable  acids ; 
solutions  of  the  preparations  of  arsenic  ;  tonics,  such  as  serpen- 
taria  virginiana,  cinchona,  tincture  of  cantharides,  bitter  sweet, 
or  sulphurous  preparations. 

I  have  confined  myself  to  the  simple  mention  of  these  reme- 
dies, as  experience  will  not  allow  me  to  speak  confidently  in  re- 
lation to  their  efficacy,  and  the  judicious  practitioner  will  neither 
reject  them  altogether,  nor  use  them  exclusively;  but  after  hav- 
ing made  trial  of  simple  and  rational  means  ineffectually,  will 
perhaps  be  obliged  to  resort  to  them  for  the  management  of  a  dis- 
ease which  often  defies  all  his  efforts,  selecting  such  as  will  do 


116  ON   THE    DISEASES    OF    INFANTS. 

the  least  injury  to  the  patient;  watching  closely  the  digestive  or- 
gans and  the  peculiar  state  of  the  constitution. 

PSORA. 

Psora  simplex.^ 
"     complex. 

Psora  is  a  vesicular  disease,  which  some  physicians,  among 
whom  is  Morgagni,  attribute  to  the  presence  of  an  insect,  (aca- 
rus  scahiei.)  M.  Gales  has  even  discovered  its  form  ;  but  MM. 
Alibert  and  Biete  have  in  vain  searched  for  it,  although  aided  by 
microscopic  instruments.* 

Psora  may  be  simple,  exhibiting  on  various  parts  of  the  body, 
but  particularly  in  the  folds  of  the  articulations,  only  the  little 
vesicles  which  are  its  characteristics.  It  may  also  be  complicat- 
ed ;  that  is  to  say,  having  between  the  vesicles  different  kinds  of 
cutaneous  inflammation ;  such  as  eczema,  prurigo,  lichen,  stro- 
phulus, ecthyma,  etc. 

In  both  cases,  it  is  almost  always  apyrectic  and  contagious  ;  it 
is  developed  in  those  children  who  are  badly  clothed  and  badly 
nourished.  It  is  usually  communicated  by  nurses,  in  which  case 
it  apppears  on  the  thighs  and  breech,  because  these  parts  are  ap- 
plied to  the  arms  of  those  persons  who  carry,  or  habitually  at- 
tend them. 

Psora  rarely  gives  rise  to  general  symptoms  of  a  serious  na- 
ture. Nevertheless,  in  young  infants  we  ought  to  exercise  a  se- 
vere scrutiny  into  all  the  symptoms  which  may,  at  the  same 
time,  be  developed  ;  and  in  the  event  of  any  important  organ  be- 
coming the  seat  of  an  inflammation  more  or  less  violent,  it  should 
be  treated  with  promptness  and  energy.  As  to  the  treatment  of 
the  cutaneous  disease  in  particular,  those  applications,  in  the  case 
of  young  infants,  ought  to  be  used  which  are  the  most  simple. 
Among  the  number  of  curative  means,  ablution  with  artificial 
Barege  water,  alternating  with  the  bath  of  marshmallows, 
or  of  bran,  will  be  found  the  most  convenient  for  children 
at  the  breast.  The  efficacy  of  these  means  has  been  proved  in 
adults,  and  in  children  more  advanced  in  age  than  those  now 

*  See  Appendix,  page  568. 


ON   THE  DISEASES   OF    INFANTS.  117 

considered  ;  but  I  have  no  doubt,  that  this  remedy  will  be  found 
equally  applicable  to  very  young  infants. 

MILIARY   SWEAT. 

The  miliary  sweat,  the  characters  of  which  have  been  already 
described,  prevails  generally  as  a  sporadic  disease.  It  is  princi- 
pally observed  in  youth  and  in  adults  ;  but  I  know  not  whether 
it  may  not  also  attack  infants  at  the  breast.  In  every  instance, 
these  children  ought  to  be  isolated,  and  all  those  not  affected,  re- 
moved from  the  country  where  it  prevails  ;  the  symptoms  of  gas- 
tritis, with  which  it  is  almost  always  complicated,  watched  with 
care ;  neither  should  the  sudorifics,  with  which  the  patients  are 
too  often  gorged,  be  allowed  to  be  administered  ;  nor  the  practice 
of  keeping  the  patient  awake  under  the  fear  that  the  brain  may 
otherwise  suffer,  be  continued. 

VARIOLA^    VARICELLA,    AND    VARIOLOID. 

Variola  is  not  a  disease  peculiar  to  infancy,  but  it  affects 
equally  individuals  of  all  ages;  yet  it  is  of  more  frequent  occur- 
rence at  the  period  of  second  infancy  than  among  infants  at  the 
breast  or  among  adults.  The  diversity  of  ages  does  not  influence 
this  disease  so  much  as  the  difference  of  the  nature  and  seat  of 
the  complications,  for  the  anatomical  character  of  the  eruption 
remains  always  the  same. 

The  history  of  this  disease  comprehends  nosological  details  of 
the  highest  interest ;  and  the  labors  of  pathologists,  in  attempting 
to  discover  the  origin  of  variola,  and  to  understand  the  true  na- 
ture of  its  varieties,  would  themselves  form  the  subject  of  an  ex- 
tended monograph.  I  will  content  myself  with  the  exposition  of 
the  facts  generally  admitted  in  relation  to  varioloid. 

This  eruption  is  ordinarily  preceded  and  accompanied  by  fe- 
ver, and  more  or  less  disorder  of  the  digestive  functions,  some- 
times by  angina,  pneumonia,  encephalitis,  or  menengitis. 

Variola  usually  passes  through  periods  distinguished  in  the 
following  manner, — that  of  irritation,  eruption,  suppuration,  and 
desquamation.  The  pustules  exhibit,  during  these  periods,  a  se- 
ries of  anatomical  characters,  which  have  been  already  described 
in  the  table  of  genera.* 

*  See  p.  88. 


118  ON    THE    DISEASES    OP    INFANTS. 

It  is  again  distinguished  into  simple,  discrete,  and  confluent. 
Some  pathoxOgists,  among  whom  is  Adolphus  Henke,*  have 
pointed  out  a  great  number  of  varieties  of  variola,  such  as  serous, 
siiiquoze,  verrucous,  sanguinolent,  or  purple,  etc.  Other  species 
have  been  denominated  catarrhal,  malignant,  nervous,  putrid — 
distinctions  which  have  been  admitted  for  a  long  time  by  the 
most  celebrated  nosologists,  such  as  Sydenham,  Van  Swieten,  and 
others. 

Without  attaching  much  importance  to  all  these  varieties,  we 
should  still  keep  two  things  in  remembrance :  sometimes  variola 
only  exhibits  the  symptoms  that  strictly  belong  to  it,  or  those 
which  result  from  its  usual  complication,  gastric  or  pulmonary 
affections  ;  sometimes,  on  the  other  hand,  inflammation  of  a  vital 
organ  ensues  suddenly;  the  practitioner  ought  then  to  direct  his 
attention  as  well  to  the  plegmasiae  thus  developed,  as  to  the  cuta- 
neous inflammation,  and  use  for  both  affections  the  suitable 
therapeutic  means  for  their  relief. 

The  term  varioloid  has  recently  been  applied  to  variolous 
eruptions  appearing  on  those  who  have  been  vaccinated.  M.  Mo- 
reau  de  Jones  asserts  that  varioloid  is  a  disease  distinct  from 
common  variola  in  its  symptoms,  its  effects,  and  in  its  origin  ; 
that  neither  the  ordinary  small-pox  nor  the  vaccine  disease  is  a 
protection  against  its  contagion  ;  that  the  vaccine  virus,  in  every 
instance,  modifies  its  pernicious  influence.  [Mem.  read  at  the 
Acad.  roy.  des  JScietice,  Oct.,  1827.)  An  attentive  examination, 
however,  has  proved  that  this  kind  of  variolous  eruption  which 
occurs  in  those  who  have  been  vaccinated,  does  not  differ,  with 
respect  to  its  anatomical  characters,  from  that  which  arises  in  pa- 
tients who  have  not  been  vaccinated ;  that  they  even  offer  the 
same  complications,  and,  in  general,  they  are  neither  more  mild 
nor  more  mortal.  Dr.  Thompson,  of  Edinburgh,  showed  me  some 
very  correct  paintings  of  variolous  eruptions  developed  after  vacci- 
nation, the  characters  of  which  did  not,  in  any  respect,  differ  from 
the  eruption  of  small-pox.  I  particularly  noticed  among  these 
drawings,  that  of  a  young  man  who  had  been  vaccinated  by 
Jenner.     The   word   varioloid,   which  Dr.  Thompson  himself 

*  Handbuch  zur  Erkenntnias  und  heilung  der  kinder krankheiien  van  A.  Henke, 
1821. 


ON   THE    DISEASES   OP    INFANTS.  119 

uses,  is  nothing  more  than  a  conventional  term  applied  to  vario- 
la arising  after  vaccination,  and  to  which  there  ought  not  to 
be  attached  any  peculiar  signification,  or  any  idea  that  will  es- 
tabhsh  or  justify  any  appreciable  difference  in  the  anatomical 
characters  of  this  disease,  in  its  form,  its  progress,  or  in  the  du- 
ration of  its  symptoms. 

The  prognosis  of  variola  is  unfavorable  in  proportion  to  the  im- 
portance of  the  organ  which  is  the  seat  of  the  complication  ; 
thus,  in  young  infants,  encephalitis,  and  particularly  meningitis, 
are  fatal  complications,  and  unhappily  of  too  frequent  occurrence. 

The  name  of  varicella  is  given  to  an  eruption,  the  form  of 
which  differs  from  that  of  variola,  properly  so  called.  Its  pecu- 
liar characters  have  been  before  described.  This  eruption,  quite 
distinct  and  very  mild,  is  rarely  accompanied  by  any  unfavorable 
symptoms ;  it  scarcely  ever  produces  fever,  and  is  to  be  found 
indifferently  in  those  who  have,  or  have  not,  been  vaccinated.  It 
usually  disappears  after  a  few  days  continuance,  and  never 
leaves  after  it  any  deep  scars. 

The  treatment  of  variola  should  be  confined  to  the  use  of  de- 
mulcent drinks,  and  to  a  strictly  antiphlogistic  regimen,  when 
there  are  no  serious  complications  added  to  the  eruption ;  but 
should  there  arise  an  intense  gastritis,  pneumonia,  angina,  or 
meningitis,  it  will  then  be  necessary  to  meet  the  complication  by 
the  use  of  appropriate  means,  which  will  be  considered  when 
treating  of  the  history  of  each  of  these  diseases.  Care  should  be 
taken  to  avoid  the  treatment  of  what  is  still  vaguely  denominated 
a  state  of  ataxia  or  putridity,  by  the  administration  of  tonics  and 
stimulants  ;  such  medicines  will  act  much  more  fatally  on  young 
children,  because  they  are  more  disposed  to  inflammation  of  the 
gastro-intestinal  apparatus,  at  all  times  much  disposed  to  phleg- 
masia. Among  all  the  means  recommended  to  facilitate  the  pro- 
gress of  the  eruption,  and  to  diminish  the  pain  and  fever,  opium 
is  the  most  prominent,  the  success  of  which  is  supported  by  the 
experience  and  authority  of  Sydenham,*  Huxham,t  Morton,!: 

*  Sydenhamii  opera,  sect.  3,  cap.  2. 
t  Opera  phys.  med. 
t  De  variolis,  cap.  7. 


120  ON   THE    DISEASES    OF    INFANTS. 

Werlhof,*  Van  Swieten,t  Frank,t  Hufeland5§  and  A.  Henke.fl 
The  latter  mentions  his  having  used  it  with  great  advantage  in 
the  small-pox,  in  1802,  at  Brunswick.  When  the  child  mani- 
fests great  distress  by  its  cries,  wakefulness,  and  restlessness,  a 
little  syrup  of  poppies  may  be  given  in  its  milk  with  advantage. 
Sydenham  never  gave  opium  except  to  patients  advanced  in  age, 
and  with  the  greatest  caution  ;  he  preferred  for  infants  laudanum 
or  syrup  of  poppies ;  but  he  never  used  it  except  compelled  by 
the  universal  excitement  of  the  patient.  This  medicine  should 
certainly  be  given  with  care ;  and  when  convulsions  arise,  a 
symptom  to  which  children  are  very  liable  in  the  course  of  va- 
riola, it  would  be  better  not  to  have  recourse  to  it  until  after 
having  endeavored  to  calm  the  irritation  of  the  patient  by  tepid 
baths  or  blood-letting,  practised  according  to  the  rules  laid  down 
in  speaking  of  the  diseases  of  the  cerebro-spinal  apparatus. 

VACCINIA. 

Is  there  any  need  of  referring  here  to  the  origin  of  the  discovery 
of  Jenner,  when  public  gratitude  has  for  ever  engraved  it  upon 
the  memory  of  men  ?  It  is  useless  any  longer  to  copy  that  which 
has  for  twenty  years  been  repeated  in  every  book  published  on 
this  subject.  We  are  indebted,  moreover,  to  the  researches  of 
G.  Pearson,  M.  Husson,  R.  Willan,  and  a  number  of  others,  for 
some  highly  valuable  documents  on  the  history  of  vaccination. 

The  process  of  vaccinating  is  so  simple  that  it  has  become 
popular,  and  its  effects  are  at  this  time  so  well  known  and  ap- 
preciated, that  no  one  can  any  longer  hesitate  to  protect  children 
by  means  of  this  preventive  from  one  of  our  most  fatal  diseases. 
Yet  the  success  of  vaccination  has  lately  been  brought  in  ques- 
tion, because  there  have  been  several  individuals  affected  with 
variola  who  had  been  vaccinated.  The  serious  doubts  raised  as 
to  the  efficacy  of  vaccination  as  a  preventive  of  small-pox,  have 
been  thought  worthy  of  the  attention  of  the  Acad^mie  royale  de 
Medecine,  and  a  commission  was  appointed  by  that  body,  charged 

*  De  variolis  et  anthracibus. 

t  G.  Van  Swieten,  comm.  in  Boerrh.  Lb. 

t  Epitome  de  curandis  hominum  morbis. 

%  Bamerkungen,  uber  naturliche  und  gaimpft  Blattem. 

II  Henke,  loco  cit. 


ON    THE    DISEASES    OF    INFANTS.  121 

with  the  examination  of  the  facts  relating  to  this  important  point 
in  pathology.  In  a  report,  remarkable  for  its  clearness,  and  for 
the  excellent  spirit  with  which  the  facts  alleged  on  both  sides  of 
the  question  were  examined,  M.  Paul  Dubois,  secretary  of  the 
commission,  has  demonstrated  that  although  vaccination  has  failed 
under  some  circumstances,  it  has  not  the  less  modified,  in  almost 
every  instance,  the  variolous  affections,  when  it  has  not  entirely 
preserved  individuals  from  an  attack  of  the  disease.  So  that  the 
discovery  of  Jenner  deserves  still  the  confidence  which  it  had 
acquired  by  its  success  in  innumerable  cases  ;  and  if  its  mfalli- 
bility  is  not  demonstrated,  it  is  at  least  impossible  to  harbor  a 
doubt  of  its  immense  utility.  M.  Moreau  de  Jones  has  remarked, 
that  the  modifying  influence  of  vaccination  is  so  great,  that,  in 
the  United  States,  among  individuals  vaccinated,  that  are  attacked 
with  variolous  disease,  scarcely  one  per  cent,  are  fatal,  whilst  one 
half  of  the  non-vaccinated,  of  those  who  take  the  disease,  die.* 

Vaccination  may  be  performed  at  all  ages  ;  yet  I  must  observe 
that  the  congestion  of  the  integuments,  during  the  early  days  of 
life,  appears  to  contra-indicate  the  operation  at  this  period.  I  have 
seen,  at  the  Hospice  des  Enfans  Trouves,  where  infants  are  vac- 
cinated very  young,  a  severe  erysipelas  form  on  the  vaccinated 
limb. 

It  will  probably  be  thought  a  proper  place  to  enter  upon  the  de- 
tails of  the  history  of  spurious  vaccination,  and  of  the  eruptions 
resembling  cow-pox,  which  are  developed  on  the  arm  after  the 
insertion  of  the  virus  ;  but,  apart  from  the  great  numoer  of  sub- 
jects of  which  I  am  obliged  to  treat  in  this  volume,  compelling 
me  to  speak  briefly  on  each,  I  feel  no  disposition  to  commence  the 
discussion  of  one  still  in  litigation. 

ECTHYMA. 

Ecthyma  vulgare, 
"        infantile, 
«         luridum, 
"         cachecticum. 

Ecthyma,  which  consists,  as  we  have  already  seen,  of  large 
pustules,   elevated  upon   a   hard,  red,  and   inflamed  base,  and 

*  See  Appendix,  page  568. 
16 


122  ON   THE    DISEASES    OF    INFANTS. 

covered  with  greenish  yellow  scabs,  is  seen  more  especially  in 
children  that  are  feeble,  badly  nourished,  and  badly  clothed. 
This  disease  is  not  contagious  ;  but  it  often  succeeds  affections 
that  possess  this  character,  such  as  variola,  rubeola,  scarlatina, 
and  psora.  In  general,  ecthyma  is  connected  with  a  chronic  af- 
fection of  the  digestive  or  respiratory  apparatus,  and  is  developed 
often  in  the  emaciated  condition  to  which  children  affected  with 
these  diseases  are  reduced. 

The  pustules  of  ecthyma  appear  more  particularly  on  the  neck, 
shoulders,  arms,  and  breast.  Sometimes  there  is  but  one  eruption 
developed,  which  runs  its  course  in  a  very  short  time ;  in  other 
cases  the  eruption  is  renewed  without  ceasing,  multiplies,  spreads, 
and  becomes  confluent.  This  difference  in  the  course  of  the  dis- 
ease, has  caused  a  division,  by  authors,  into  acute  and  chronic ; 
in  both  cases  there  is  always  lassitude,  rapid  emaciation,  and  other 
violent  symptoms. 

Bateman,  regarding  only  the  state  of  cachexia  which  accom- 
panies ecthyma,  has  recommended  the  use  of  tonics,  such  as  cin- 
chona, Virginia  snake  root,  sarsaparilla,  and  the  preparations  of 
antimony.  But  would  it  not  be  better  at  first  to  remove  the  child 
from  the  external  causes  capable  of  keeping  up  the  wasted  and 
debilitated  condition,  to  subject  it  to  a  better  directed  and  more 
suitable  diet ;  to  immerse  it  in  mucilaginous  and  emollient  baths, 
and  to  consider  the  condition  of  the  digestive  organs  before  ad- 
mitting tonics  ?  As  to  the  external  treatment,  it  should  consist 
of  emollient  appUcations. 

ACNE. 

Acne  simplex, 
"    punctata^ 
"     indurata. 

Acne  has  not  as  yet  been  observed  in  infants  at  the  breast ;  it 
is  scarcely  ever  developed  until  after  puberty ;  I  must  therefore 
refer,  for  the  detailed  history  of  this  disease,  to  works  ex  professo 
on  cutaneous  diseases. 

MENTAGRA. 

Mentagra  is  not  an  infantile  disease  ;  it  appears  almost  always 
hi  adults,  and  particularly  in  those  persons  in  whom  the  chin  is 
covered  with  a  thick  strong  beard.     It  should  not  be  confounded 


ON   THE    DISEASES    OF    INFANTS.  123 

with  porrigo  larvalis,  which  sometimes  appears  at  first  on  the 
chin. 

IMPETIGO. 

Impetigo  Jlgurata, 

"  sparsa^ 

«  erysipelatodes, 

"  scabida, 

"  rodens. 

The  varieties  of  impetigo  described  by  Bateman,  are  evidently 
too  numerous,  and  I  think  it  would  be  much  better  to  have  but 
two,  as  described  by  M.  Rayer — impetigo  ^^wra^a  and  impetigo 
spars  a. 

Impetigo  figurata  ordinarily  appears  under  the  form  of  patches 
resulting  from  the  agglomeration  of  several  small  pustules,  which 
soon  excoriating,  form  thin  yellow  scabs,  slightly  prominent, 
surrounded  by  an  inflammatory  circle,  and  occurring  principally 
on  the  face  and  limbs. 

Impetigo  sparsa  consists  of  various  collections  of  pustules, 
which  are  developed  separately  on  several  parts  of  the  body,  but 
especially  on  the  inferior  extremities,  fore-arm,  wrist,  and  ankle. 

It  may  be  either  acute  or  chronic,  and  may  exist  with  or  with- 
out disturbance  of  the  digestive  functions.  It  is  a  disease  of  much 
more  frequent  occurrence  in  adults  than  in  children ;  yet  au- 
thors place  among  its  predisposing  causes,  the  first  and  second 
dentition.  1  have  never  met  with  it  in  infants  at  the  breast ; 
they  are,  however,  greatly  subject  to  various  kinds  of  tenia,  and 
there  exists  so  much  resemblance  between  tenia  mucosa  and  im- 
petigo sparsa^  that  it  is  difficult  to  establish  a  well-defined  line 
of  demarcation. 

Besides,  impetigo,  according  to  Bateman,  may  follow  tenia 
mucosa,  (Porrigo  larvalis—WiWoxi])  and  according  to  some  au- 
thors, the  shades  which  are  observed  between  tenia  mucosa, 
and  impetigo  sparsa,  result  entirely  from  the  different  regions  in 
which  the  pustules  are  developed,  and  from  the  no  less  remarka- 
ble difference  of  the  ages  of  the  individuals  affected  with  the  dis- 
ease.* 

*  Rayer,  Traite  des  McUadiee  de  la  peau,  Ist  vol.  p.  479. 


124  ON*   THE    DISEASES    OP    INFANTS. 

Be  this  as  it  may,  if  well  marked  impetigo  is  met  with  in  an 
infant,  the  plethoric  condition  should  be  relieved  if  it  exist,  and 
the  gastro-intestinal  complications  closely  watched;  the  cuta- 
neous inflammation  moderated  by  the  use  of  tepid  baths,  of  sim- 
ple water,  or  bran  water,  by  lotions  made  with  marshmallow 
roots,  to  which  poppy  heads  or  the  extract  of  opium  may  be 
added.  Finally,  Rayer  has  advised  the  use  of  mild  ointment  of 
oxide  of  zinc  and  acetate  of  lead,  in  order  to  relieve  the  inflam- 
mation- Neither  douches  nor  vapor  baths  should  be  used  until 
the  inflammatory  period  is  passed.  It  should  not  be  forgotten 
that  impetigo  is  developed  usually  in  those  children  who  have 
been  previously  much  reduced  by  other  chronic  cutaneous  affec- 
tions, and  that  it  is  often  accompanied  by  a  violent  itching  and 
great  intestinal  irritation,  arresting  their  sleep  and  disturbing 
their  digestive  organs,  reducing  them  to  marasmus,  and  exposing 
them  to  lymphatic  engorgements  of  the  neck  and  mesentery.  It 
would,  no  doubt,  be  proper,  under  these  circumstances,  to  have 
recourse  to  sea-bathing,  or  baths  of  Barege  water,  and  to  use  all 
other  means  for  the  renovation  of  the  general  health  ot  the  pa- 
tient. 

"TEIGNE    PAVEUSE" PORRIGO   LUPINOSA.* 

This  disease  is  much  more  common  in  children  of  the  age  of 
seven,  eight,  or  nine  years,  than  in  those  still  at  the  breast ;  it  is 
usually  seated  on  the  scalp,  and  is  communicated  by  contact  and 
by  the  use  of  the  same  brushes  or  combs.  It  may  occupy  other 
parts  besides  the  head.  I  have  twice  seen  it,  at  the  Hospice  des 
Enfans  Trouves,  appear  on  the  inferior  extremities  of  very 
young  infants;  in  one  of  the  two  particularly,  the  peculiar  char- 
acters of  the  disease  were  very  strongly  marked ;  it  was  develop- 
ed on  the  posterior  and  lateral  parts  of  the  thighs.  This  child 
was  three  weeks  old  when  it  was  exposed,  so  that  the  affection 
might  easily  have  been  communicated  by  contact,  during  its  so- 
journ with  its  parents.  The  inflammation  and  the  scabs  disap- 
peared at  the  end  of  fifteen  days,  after  the  use  of  nothing  more 
than  bran  baths  and  emollient  lotions.     There  remained  in  their 

*  This  disease  has  been  confounded  with  Toxrigo  favosa,  but  it  is  evidently  Porrigo 
lupinosa  of  English  authors,  as  may  be  seen  by  comparing  the  doscriptions  of  them. 
See  Plumbe  on  the  diseases  of  the  skin. — S. 


ON   THE    DISEASES    OF    INFANTS.  125 

places  violet-red  spots,  which  began  to  fade  in  about  three  weeks 
after  the  period  when  the  child  was  sent  into  the  country. 

The  "teigne  faveuse"  is  developed  more  frequently  in  the 
scalp  ;  to  the  pustules  succeed  scabs,  which  enlarge,  mingle  to- 
gether, and  form  a  great  number  of  cup-like  hollows,  bearing 
some  resemblance  to  a  honey-comb,  or  to  the  depressions  in  a 
lupin-seed,  or  to  the  fructification  of  certain  species  of  Uchen. 
When  the  disease  has  recently  appeared,  they  are  either  of  a  yel- 
low or  fawn  color,  but  as  they  grow  old  they  become  white,  break 
and  detach  themselves  from  the  scalp  in  the  pulverulent  form. 

When  the  inflammation  has  continued  for  some  time,  the  bulbs 
of  the  hair  become  affected,  and  are  altered  or  destroyed  in  such 
a  manner  as  to  cause  the  hair  to  fall,  leaving  the  skin  smooth 
and  white.  The  surrounding  cellular  tissue  becomes  the  seat  of 
a  chronic  abscess,  the  glands  of  the  neck  at  the  same  time  swell, 
and  it  is  not  unusual  to  find  the  disease  complicated  with 
ophthalmia,  coryza,  and  chronic  inflammation  of  the  stomach  and 
intestines. 

When  the  pustules  and  scabs  are  few  in  number,  and  of  limit- 
ed extent,  all  that  is  necessary  is  the  application  of  emollient  lo- 
tions to  the  head,  together  with  revulsives  to  the  skin  or  bowels. 
For  this  purpose,  the  child  may  take  a  little  manna,  or  super  tar- 
trate of  potass,  dissolved  in  whey,  and  a  blister  may  be  applied  to 
one  of  the  arms ;  the  head  should,  at  the  same  time,  be  washed 
with  a  decoction  ot  poppy-heads,  or  of  marshmallows,  or  with 
tepid  water  ;  cleanliness  is  of  the  greatest  importance  to  prevent 
the  multiplication  of  pediculi,  which  are  generally  produced  in 
great  numbers  beneath  the  scabs. 

If  the  pileous  follicles  have  been  disorganized  by  inflammation, 
the  removal  of  the  hairs  becomes  indispensable  ;  yet  it  ought  to  be 
deferred  as  long  as  possible  if  the  infant  be  very  young  or  feeble  ; 
but  when  age  and  strength  will  allow  of  this  treatment,  we  should 
not  hesitate  about  using  it  early  in  the  disease. 

The  method  of  treatment  adopted  by  the  freres  Mahon,  is  the 
best  that  can  be  used  for  this  purpose  ;  it  consists — 1st,  In 
cleansing  the  scalp,  and  preserving  it  clean  by  the  use  of  linseed 
poultices  and  saponaceous  lotions ;  2dly,  In  cautiously  and  ten- 
derly removing  the  hair.  The  following,  according  to  M.  Rayer, 
is  the  treatment  of  the  freres  Mahon.     The  part  on  which  the 


126  ON   THE    DISEASES    OP   INFANTS. 

disease  is  developed,  is  anointed  every  other  day  with  a  depila- 
tory cerate  composed  of  four  ounces  of  lard,  and  of  one  powder 
marked  No.  1.  The  application  of  this  must  be  continued  for 
the  space  of  one  month  and  a  half,  or  two  months,  according  to 
the  obstinacy  of  the  disease.  On  the  intermediate  days,  the  hair 
should  be  combed  with  a  fine-toothed  comb,  by  which  it  is  de- 
tached without  pain.  After  using  these  dressings  for  fifteen  days, 
a  small  quantity  of  depilatory  powder.  No.  2,  is  sprinkled  through 
the  hair  once  a  week.  The  following  day,  the  hair  on  the  dis- 
eased parts  is  combed,  and  the  depilatory  cerate  reapplied  ;  this 
is  continued  for  a  month  or  six  weeks.  Another  depilatory  ce- 
rate is  then  used,  consisting  of  four  ounces  of  lard,  and  of  one 
powder,  No.  3,  with  which  the  part  is  anointed  for  fifteen 
days,  or  more,  according  to  the  severity  of  the  disease  ;  after  this 
it  is  only  applied  twice  a  week,  until  the  redness  of  the  skin  has 
disappeared  ;  on  the  days  on  which  the  cerate  is  not  used,  the 
patient's  hair  should  be  combed  once  or  twice  in  twenty-four 
hours,  taking  the  precaution  not  to  press  the  comb  on  the  skin. 

This  method  has  been  attended  with  great  success,  and  is  of 
very  easy  application  to  children  at  the  breast.*  M.  Rayer  has 
given  a  remarkable  example,  the  subject  of  which  was  a  little 
girl  aged  three  months,  affected  with  tinea  of  the  scalp,  treated, 
on  the  14th  February,  1826,  according  to  the  method  of  Mahon, 
and  cured  on  the  9th  of  May,  of  the  same  year.  M.  Rayer  also 
treated  with  success  a  little  girl  who  had  been  affected  with  the 
disease  from  earlist  infancy,  and  who,  at  the  time  of  his  attend- 
ance, had  been  just  weaned.  "  I  shaved  the  head  of  this  child," 
says  M.  Rayer,  "  and  covered  it  with  a  flaxseed  poultice  ;  the 
scabs  softened  and  soon  became  detached  ;  the  head  was  washed 
every  day  with  a  decoction  of  flaxseed  ;  at  the  end  of  four  or  five 
days  it  was  perfectly  clean  ;  I  then  applied  a  blister  to  each  arm, 
andkeptthem  discharging  for  three  months,  and  every  day  washed 
the  head  myself  with  a  decoction  of  flaxseed ;  I  thus  obtained  a 
cure  of  this  case  of  tinea  without  depilation  ;  the  blisters  were 
then  permited  gradually  to  heal." 

I  think  it  most  rational  to  attempt  the  cure  of  tinea  by  simple 
antiphlogistic  means,  before  the  adoption  of  any  other  course,  and 
not  to  have  recourse  to  depilation  until  other  measures    have 

*  Recherches  sur  la  siege  et  la  nature  des  Teignes,  par  Mah(m,  jeune,  1839. 


ON  THE    DISEASES    OF    INFANTS,  127 

failed.     In  every  instance  we  should  renounce  the  use  of  the 
pitch  capj  still  in  use  in  some  parts  of  the  country. 

TINEA    ANNULARIS. 

This  disease  is  very  rare  in  sucking  children  ;  it  generally  ap- 
pears between  the  age  of  two  years  and  puberty.  It  is  evidently 
contagious,  and  is  one  of  the  most  obstinate  inflammations  of  the 
scalp.  The  same  method  of  treatment  should  be  adopted  for  this 
as  for  the  preceding  diseases. 

TINEA    GRANULATA. 

Tinea  granulata,  the  distinctive  characters  of  which  have  al- 
ready been  described,  is  of  less  frequent  occurrence  than  "  teigne 
faveuse,"  and  is  rarely  to  be  seen  in  nursing  infants.  It  is  ordna- 
rily  accompanied  with  the  same  general  symptoms,  and  requires 
nearly  the  same  treatment  as  "  teigne  faveuse." 

TINEA    MUCOSA PORRIGO    LARVALIS. 

This  aifection  is  extremely  frequent  in  infants  at  the  breast ; 
it  usually  shows  itself  about  the  age  of  three,  five,  or  eight  months. 
It  is  neither  contagious  nor  dangerous  ;  and  it  is  very  rare  to  see 
any  of  the  children  die  with  it.  Common  people,  who  are  easily 
led  to  adopt  the  theory  of  a  corruption  of  humors,  habitually  re- 
gard this  affection  of  the  scalp  as  a  salutary  depuration.  What- 
ever foundation  there  is  for  this  opinion,  it  is  proved  that,  during 
the  course  of  the  disease,  children  rarely  exhibit  any  gastric  or 
thoracic  complications,  which  so  often  render  cutaneous  diseases 
fatal ;  and  tenia  mucosa  ordinarily  disappears  without  leaving  after 
it  any  of  those  serious  affections  of  the  constitution  which  some  in- 
dividuals experience  after  certain  cutaneous  diseases.  I  have 
seen  a  great  number  of  sucking  infants  affected  with  tenia  mu- 
cosa, at  the  Hospice  des  Enfans  Trouves;  very  few  of  them 
perished,  but  the  greater  number  exhibited,  after  the  disappear- 
ance of  this  inflarnmation,  a  state  of  vigor  and  embonpoint,  which 
appeared  to  give  some  support  to  the  popular  opinion  just  men- 
tioned. However,  I  am  far  from  thinking  that  this  general 
assertion  admits  of  no  exceptions  ;  and  I  believe  it  possible  thai 
the  disease  may  be  complicated  with  an  inflammation  of  the  pri- 
mse  via3,  of  greater  or  less  intensity. 

It  may  exist  in  ah  acute  or  chronic  state ;  may  confine  its  ra- 


128 


ON   THE    DISEASES    OF    INFANTS. 


vages  to  the  scalp,  or  extend  them  to  the  face  and  neck ;  may  be 
with  or  without  fever;  and  may  sometimes  form  small  phleg- 
monous tumors  about  the  ears  and  surface  of  the  cranium,  from 
which  arise  the  engorgement  of  the  lymphatic  glands  of  the 
neck.  We  see  it  also  complicated  with  apthge,  angina,  ophthal- 
mia, and  existing  in  connexion  with  other  cutaneous  phlegmasiae. 
Simple  emollient  lotions  to  the  inflamed  parts,  together  with 
small  doses  of  calomel,  for  the  purpose  of  producing  a  revulsion 
on  the  intestinal  canal,  constitute  the  treatment  of  the  acute  form 
of  this  disease.  But  if  it  assume  a  chronic  form,  and  resist  these 
simple  means;  and  if,  by  reason  of  the  abundant  excretion,  the 
strength  of  the  child  be  wasted  :  and  if  it  spread  to  the  face,  ox 
to  the  superior  parts  of  the  neck,  causing  chronic  engorgements  of 
the  lymphatic  glands,  it  then  becomes  necessary  to  employ  more 
energetic  measures,  such  as  counter  irritants  to  the  skin,  drinks 
rendered  slightly  tonic,  a  nourishing  diet,  sulphurous  lotions, 
saturnine  cerate,  and  ointment  of  zinc,  or  of  nitrate  of  mercury, 
to  change  the  nature  of  the  cutaneous  irritation.  It  is  rare  that 
recourse  to  depilation  is  necessary,  the  inflammation  seldom  at- 
tacking the  bulbs  of  the  hair,  and  seldom  leaves  cicatrices,  so 
superficial  is  its  situation.  The  different  complications,  such  as 
ophthalmia,  gastro-enteritis,  thrush,  etc.,  should  be  met  by  appro- 
priate treatment.* 

PRURIGO. 

Prurigo  mitis, 
"        formicans, 
"         senilis. 
"         infantilis. 

This  papular  inflammation,  characterized  by  the  great  itching 
which  it  produces,  is  often  complicated  with  gastro-intestinal  in- 
flammation ;  it  is  observed  both  in  children  and  old  people,  it  is, 

*  Dr.  Jemina  has  published  a  number  of  cases  showing  the  complete  efficacy  of  su- 
pertartrate  of  potass  in  the  treatment  of  tenia  mucosa  of  the  face,  (Porrigo  larvalis — Wil- 
lan,)  in  nursing  infants.  This  medicine  is  administered  through  the  medium  of  the 
nurse.  The  usual  dose  is  from  one  to  two  drachms  in  a  pound  and  a  half  to  two  pounds 
of  the  decoction  of  dog-grass,  (Triticum  repens,)  sweetened.  This  should  be  given  to 
the  nurse  during  the  day,  and  repeated  daily  until  a  cure  is  elTected.  It  is  specially  ap- 
plicable to  those  cases  which  have  obstinately  resisted  all  the  usual  means  of  treatment. 
V.  Observations  du  Docteur  Jemina,  in  the  Archives  general  de  medicine,  v.  21, 1829, 


ON   THE    DISEASES   OP    INFANTS.  129 

however,  a  little  less  rare  in  young  infants,  and  on  this  account 
there  have  been  formed  two  varieties,  referring  to  the  age  of  the 
individual  affected — prurigo  senilis,  and  prurigo  infantilis.  It 
is  with  the  latter  only,  in  this  work,  that  I  have  any  interest,  and 
shall  commence  by  presenting  an  example  of  the  disease* 

CASE  VII.  In  the  month  of  September,  1826,  a  little  girl,  aged 
about  six  or  seven  months,  was  brought  to  the  Hospice  des  Enfans 
Trouves.  She  was  pale,  emaciated,  and  affected  With  a  copious 
diarrhoea,  and  a  slight  ophthalmia.  The  filthy  and  ragged  condi- 
tion of  the  clothes,  with  the  general  appearance  of  wretchedness,  de- 
noted the  extreme  poverty  in  which  she  had  lived ;  she  cried  almost 
constantly,  seized  the  breast  with  the  utmost  eagerness,  and  did  not 
enjoy  a  moment's  repose  ;  upon  the  face,  neck,  and  fore-arms,  there 
were  a  great  number  of  small,  slightly  prominent  papulae,  torn  stnd 
bloody,  or  covered  with  black  crusts  formed  no  doubt  by  the  desic- 
cation of  the  blood.  The  legs  and  body  also  presented  small  pa- 
pulae, much  more  evident  to  the  touch  than  to  the  sight ;  but  these 
parts  being  covered,  and  the  child  on  this  account  not  being  able  to 
scratch  them,  they  were  not  at  all  torn.  Besides  this,  there  were 
marks  over  the  whole  body  of  innumerable  flea-bites,  so  that  this 
little  child  appeared  to  have  been  for  a  long  time  a  prey  to  the  two- 
fold pain  caused  by  the  violence  of  the  disease,  and  the  bites  of  the 
insects  by  which  she  was  devoured. 

This  child  was  immersed  in  a  decoction  of  marshmallows,  and  the 
limbs  and  body  anointed  with  oil  of  sweet  almonds,  carefully  cover- 
ing Tip  the  hands  and  arms.  Rice  water,  sweetened  with  the  syrup 
of  marshmallows,  was  administered  internally,  and  milk  and  water 
was  given  for  nourishment. 

The  pain,  cries,  and  wakefulness  lasted  for  some  dayS^  but  the 
cutaneous  irritation  having  been  at  last  allayed,  the  child  became 
more  calm,  the  functions  of  digestion  were  soon  restored,  sleep  re- 
turned, and  at  the  end  of  fifteen  days  no  other  traces  of  the  disease 
remained,  than  a  few  violet  spots  on  the  neck  and  superior  extremi- 
ties. Three  weeks  after,  when  the  strength  had  already  begun  to 
return,  the  child  was  returned  to  the  parents,  at  whose  residence  no 
doubt  there  still  existed  the  causes  which  had  produced  the  disease, 
and  to  a  return  of  which  she  was  inevitably  exposed  by  their  ex- 
treme wretchedness. 

Thus  poverty  and  filth  may  become  a  cause  of  prurigo  in 

young  infants.     It  may  be  local  or  general,  simple,  or  complica- 

17 


130  ON   THE    DISEASES    OP   INFANTS. 

ted  with  another  affection  of  the  skin,  but  particularly  with 
lichen  or  psora. 

In  general  prurigo,  emollient,  saponaceous  or  sulphurous  baths, 
demulcent  or  slightly  acidulated  drinks,  constitute  the  treatment. 
In  local  prurigo,  it  will  be  necessary  to  apply  emollient,  sulphu- 
rous, or  alkaline  lotions  alternately  to  the  diseased  parts.  Gelati- 
no-sulphurous  douches  have  been  employed  with  success.  The 
greatest  care  should  be  used  to  accomplish  the  early  removal  of 
the  prurigo  that  is  developed  around  the  vulva  or  anus  in  chil- 
dren advanced  in  age,  because  the  excessive  itching  of  these  parts 
compelling  the  child  to  scratch  them  constantly,  they  may  there- 
by continue  in  a  state  of  erythism  and  irritation,  extremely  preju- 
dicial to  their  health. 

The  works  of  MM.  Alibert,  Mouronval,  and  Rayer,  on  cuta- 
neous diseases,  may  be  consulted  with  advantage  for  detailed  ac- 
counts of  prurigo. 

STROPHULUS. 

Strophulus  intertinctits, 
"  albidus, 

"  confertus, 

"  volalicusj 

"  candidus. 

Strophulus  is  a  very  common  disease  in  sucking  children  ;  it 
exhibits  several  varieties,  on  which  I  shall  offer  some  remarks.  I 
refer  particularly  to  those  which  Bateman  has  described,  under 
the  names  candidus  and  alhidiis. 

Strophulus  candidusj  which,  according  to  the  English  patho- 
logist, consists  of  medium-sized  pimples,  having  a  smooth  and 
shining  surface,  and  of  a  lighter  color  than  the  surrounding  skin, 
is  seen  upon  the  shoulders  and  arms  at  the  same  time  that  porri- 
go  larvalis  affects  the  face.  I  have  twice  seen  an  eruption  of 
this  species ;  it  occurred  once  in  a  little  girl  of  five  months,  and 
occupied  the  neck  and  arms ;  she  was  at  the  same  time  affected 
with  tenia  mucosa  and  gastro-enteritis.  She  died,  and  upon  dis- 
secting the  pimple,  and  examining  it  carefully,  I  discovered  that 
it  enclosed  a  small  quantity  of  puriform  matter.  There  were 
three  pimples  of  this  kind  on  the  right  arm,  and  two  on  the  neck ; 


ON   THE    DISEASES    OP    INFANTS.  131 

each  of  them  presented  the  same  phenomenon.  In  a  httle  boy, 
aged  fifteen  days,  two  pimples,  large,  hard,  and  of  a  white  ap- 
pearance, were  developed  on  the  face  without  any  known  cause  ; 
he  remained  eight  days  in  this  condition ;  at  the  end  of  which 
time,  the  pellicle  that  covered  them  softened,  became  broken,  and 
the  pimples  were  replaced  by  small  yellow  scales,  which  soon  fell 
off,  leaving  the  skin  they  had  covered  of  a  violet  color. 

From  these  considerations,  we  are  led  to  believe  that  strophu- 
lus condidus  is  not,  properly  speaking,  a  papular  but  a  pustular 
disease,  which  can  be  referred  to  a  particular  species  of  pustules 
existing  at  the  same  time  on  other  parts  of  the  body  of  the  child. 

As  to  strophulus  albidus,  it  has  not  been  in  my  power  to 
make  the  same  observations  in  relation  to  it;  but  as  it  scarcely 
differs  from  the  former  except  in  the  red  circle  that  surrounds 
the  base,  the  same  remarks,  I  think,  are  applicable  to  this  disease. 

With  regard  to  the  other  varieties,  the  same  remark  does  not 
apply,  they  all  preserve  the  distinctive  marks  of  their  species  ; 
they  consist  of  small  pimples  of  a  red  color,  more  or  less  deep, 
slightly  prominent,  grouped  or  scattered  over  the  face,  body,  and 
limbs,  and  are  described  by  authors  in  various  treatises  on  dis- 
eases of  children,  by  the  vague  terms  of  "  boutons,"  "  rongeurs," 
"  elevures,"  "  feux  de  dents,"  etc. 

Strophulus  intertinctus  is  known  by  the  existence  of  bright  red 
pimples,  disseminated  over  the  face,  limbs,  or  hands,  with  ery- 
thematic  patches  between  them. 

Strophulus  confertus  consists  in  a  large  number  of  pimples, 
more  or  less  approximated,  of  variable  diameter,  imparting  to  the 
body,  by  their  re -union  and  their  number,  a  red  tint,  more  or  less 
deep. 

Strophulus  volaticus  is,  without  contradiction,  the  most  fre- 
quent in  children  ;  yet  it  is  sometimes  seen  in  adults  ;*  in  the 
summer,  particularly,  it  prevails  among  the  children  nursed  at 
the  Hospice  des  Enfans  Trouves.  It  consists  of  small  circular 
pimples,  grouped  on  the  cheeks  and  body,  which,  upon  disap- 
pearing, are  replaced  by  other  pimples,  themselves  in  turn  un- 

*  I  once  knew  a  lady,  32  years  of  age,  affected  with  a  chronic  disorder  of  the  diges- 
tive organs,  on  whose  arms  and  hands  a  number  of  pimples  of  strophulus  volaticus 
appeared  every  time  the  symptoms  of  inflammation  became  exasperated. 


132  ON   THE    DISEASES    OF    INFANTS. 

dergoing  the  same  change.  This  eruption  often  continues  seve- 
ral weeks. 

Bateman,  I  think,  has  greatly  exaggerated  the  complications  of 
strophulus  :  it  is  true  that  it  is  sometimes  accompanied  with  gas- 
tritis, or  gastro-enteritis,  but  more  frequently  they  either  do  not 
exist,  or  the  symptoms  are  very  light ;  and  among  the  children  I 
have  seen  with  strophulus  at  the  Hospice  des  Enfans  Trouves, 
there  was  but  a  very  small  number  with  sufficient  disease  to 
allow  of  their  admission  to  the  infirmary. 

Yet  as  strophuhis  often  appears  at  the  period  of  dentition,  when 
a  great  number  of  infantile  diseases  are  developed,  it  is  not  sur- 
prising that  symptoms  of  intestinal  disorder  have  been  at  the 
same  time  observed. 

Strophulus  for  itself  requires  no  treatment;  the  complications, 
however,  should  be  met  by  means  applicable  to  each  of  them. 


LICHEN. 

lichei 

1  simples, 

a 

pilaris. 

n 

circumscripfusj 

11 

agrius, 

i( 

lividusj 

u 

urticatus, 

u 

tromcMs. 

Lichen  is  a  disease  of  more  frequent  occurrence  in  children  of 
the  age  of  eight  or  nine  years,  and  in  adults,  than  in  children  at 
the  breast ;  I  have  never  yet  seen  any  case  of  it  in  the  latter.  In 
every  instance,  this  affection  can  be  recognized  by  the  characters 
which  it  preserves  in  all  its  varieties. 

Lichen  simplex  consists  of  small  pimples  developed  on  the 
face  and  arms,  accompanied,  on  the  first  appearance,  with  fever, 
and  often  succeeded  by  exfoliations  of  a  pulverulent  kind.  Ac- 
cording to  Lorry,  it  may  re-appear  anew  in  the  same  individual 
every  summer. 

In  lichen  pilaris  the  pimples  show  themselves  at  the  roots  of 
the  hairs  of  the  skin. 

Patches,  or  the  union  of  pimples,  in  a  circular  form,  character- 
ize lichen  circumscriptus. 

Lichen  agrius,  one  of  the  most  serious  from  its  complications, 


ON   THE    DISEASES    OP    INFANTS.  133 

and  especially  from  the  febrile  state  with  which  it  is  accompanied, 
manifests  itself  under  the  form  of  large  red,  highly  inflamed,  and 
painful  pimples  ;  they  soon  become  excoriated,  and  are  covered 
with  scabs,  bearing  some  resemblance  to  impetigo. 

Lichen  lividus  is  known  by  the  livid  color  of  the  pimples  and 
the  petechias  mixed  with  them.  Lichen  urticatus  is  remarkable 
for  the  resemblance  which  the  pimples  bear  to  the  marks  left  by 
the  pricking  of  nettles ;  and  Bateman  has  included  under  the 
name  of  lichen  tropicus^  the  eruptions  produced  by  the  influence 
of  a  tropical  climate. 

Emollient  baths,  during  the  inflammatory  stage  of  lichen, 
sulphurous  baths  and  saturnine  lotions,  acidulated  drinks,  sul- 
phuric lemonade,  towards  the  termination  of  the  disease  ;  finally, 
the  removal  from  the  atmospheric  causes  producing  lichen,  should 
form  the  base  of  the  treatment.  For  further  details  of  treatment, 
the  works  of  Bateman,  Alibert,  and  Rayer,  may  be  consulted. 

CANCER — LUPUS — ELEPHANTIASIS. 

Cancer,  lupus,  and  Greek  elephantiasis,  are  not  properly  in- 
fantile diseases  :  their  history  will  be  found  in  works  of  general 
pathology. 

LEPRA. 

Lepra  vulgaris^ 
"      alphoides, 


1  do  not  believe  that  lepra  has  been  observed  in  infants  at  the 
breast.  M.  Baron,  whose  experience  ought  to  be  authority,  has 
never  seen  it  at  the  Hospice  des  Enfans  Trouves ;  and  Rayer 
says  he  never  met  with  it  in  young  infants.  But  this  remark  is 
not  applicable  after  the  first  dentition,  for  the  different  varieties 
have  been  often  seen  at  the  Hospice  des  Enfans  Malade.  For  the 
history  of  this  disease,  the  work  of  Alibert,  and  the  excellent 
chapter  of  Rayer  on  this  subject,  may  be  consulted. 

PSORIASIS. 

Psoriasis  guttata^ 
"  diffusa^ 
"  gyrata, 
"       inveterata. 


134  ON   THE    DISEASES    OP    INFANTS. 

Psoriasis  may  attack  children  at  the  breast ;  besides,  it  is  one 
of  those  cutaneous  diseases  which  are  evidently  hereditary.  It 
has  often  been  described  under  the  name  of  "  dartre  squameuse," 
or  confounded  with  lepra ;  it  has  also  sometimes  been  mistaken 
for  syphilitic  pustules.  These  mistakes  may  be  avoided  by  pay- 
ing attention  to  the  anatomical  characters  appertaining  to  this 
disease,  and  which  we  have  endeavored  to  exhibit  in  the  preced- 
ing tables. 

Psoriasis  guttata  consists  in  small  squamous  patches  covering 
small  solid  elevations,  red,  and  of  the  size  of  a  pin's  head,  the 
summits  of  which  are  soon  covered  with  little,  dry,  white  scales. 
The  centre  of  each  of  these  patches  is  always  more  elevated  than 
the  borders ;  the  intervals  whicli  separate  them  are  of  various 
extent,  and  they  are  surrounded  by  an  inflammatory  circle. 
When  the  patches  are  elongated  in  a  spiral  form,  they  are  de- 
nominated psoriasis  gyrata.  If  the  patches  increase  in  number, 
spread,  and  mingle,  it  is  then  denominated  psoriasis  diffusa. 
When  the  squamous  inflammation  continues  several  months  or 
several  years,  it  receives  the  name  of  inveterata  ;  formerly  the 
appellation  of  agria  was  given  to  this  variety ;  and  as  the  skin 
then  assumes  an  appearance  analogous  to  the  bark  of  trees,  cov- 
ered with  lichens,  Alibert  has  described  this  disease  under  the 
name  of  "  dartre  squameuse  lichenoides 

Psoriasis  may  be  developed  on  the  scalp,  face,  about  the  eyes, 
(psorophthalmia,)  around  the  lips,  on  the  trunk,  scrotum,  pre- 
puce, hands,  feet,  or  other  parts  of  the  limbs. 

Children  can  be  affected  with  psoriasis  from  the  age  of  two 
months  to  two  years,  which,  according  to  Bateman,  has  induced 
Willan  to  make  a  distinct  species  called  psoriasis  infantilis.  The 
following  case  will  furnish  an  instance  of  this  species. 

CASE  VIII. — Joseph,  aged  three  months,  was  suckled  for  two 
months  and  a  half  at  the  Hospice  des  Enfans  Trouves ;  he  was  thin, 
pale,  and  miserably  wretched ;  and  had  been  frequently  affected  with 
diarrhoea,  and  sometimes  vomited  the  milk  shortly  after  sucking.  He 
was  sent  to  the  infirmary  on  the  25th  of  May,  1826,  for  a  cutaneous 
affection  of  ten  days  standing ;  this  affection  consisted  in  a  gray 
scaly  patch,  irregular  in  its  form,  three  lines  in  breadth,  and  half  an 
inch  in  length,  between  the  chin  and  lower  lip.  This  scale  was  su- 
perficial, and  surrounded  by  a  small  red  circle,  and  had  begun   to 


ON   THE    DISEASES    OF    INFANTS.  135 

crack  in  the  centre.  There  also  existed  two  others,  much  longer, 
but  not  less  irregular,  on  the  internal  portion  of  the  right  fore-arm  ; 
there  was  a  third,  about  the  size  of  a  two  franc  piece,  on  the  left  hip. 
These  scales  were  slightly  salient,  and  their  borders  surrounded  by 
a  bright  red  line,  resembling  the  colored  lines  used  to  designate  the 
limits  of  a  country  on  a  map. 

The  child  was  weaned ;  milk  and  water  sweetened  were  given  for 
drink,  and  every  morning  he  was  immersed  for  half  an  hour  in  a  bran 
bath. 

Sleeplessness,  pain,  manifested  by  his  cries,  his  progressive  emacia- 
tion, and  the  continued  diarrhoea,  hastened  the  approach  of  death. 
On  the  eighth  day  after  his  entrance  into  the  infirmary,  he  succumbed ; 
when  the  scales  detached  were  no  longer  reproduced,  leaving  the 
skin  covered  with  small  slightly  projecting  pimples,  and  of  a  violet 
color,  on  the  places  which  had  been  covered  with  the  scales.  A 
violent  inflammation  of  the  colon  was  discovered  on  examining  the 
body.     All  the  other  organs  were  in  a  healthy  state. 

The  treatment  of  psoriasis  should  be  more  or  less  active,  in 
proportion  to  the  recent  invasion  or  long  continuance  of  the  dis- 
ease ;  in  the  former  case  it  will  be  sufficient  to  use  emollient  ap- 
plications, either  by  effusion  or  bathing,  until  the  irritation  of 
the  skin  is  relieved,  and  the  scabs,  which  form  without  ceasing 
on  the  inflammatory  parts,  are  removed.  In  the  latter  case,  the 
chronic  inflammation  of  the  integuments  should  be  first  attended 
to ;  and  afterwards,  the  actual  condition  of  the  constitution  of  the 
patient. 

To  accomplish  the  first  object,  emollient  and  narcotic  baths 
have  been  recommended ;  and  for  the  second,  internal  remedies 
have  been  highly  extolled,  such  as  epsom  salts,  subcarbonate  of 
potass,  calomel,  resin  of  jalap,  tincture  of  cantnarides,  arsenical 
preparations  continued  for  several  months  ;  this  method  appears 
to  us  an  irrational  one,  and  M.  Rayer  has  offered  the  following 
remarks  in  relation  to  it.  "  To  submit  a  patient,  affected  with 
obstinate  psoriasis,  to  arsenical  treatment,  in  the  faint  hope  of 
producing  a  transient  relief,  is  certainly  to  expose  him  to  the  fa- 
tal effects  of  disease  in  the  internal  organs,  which  are  much  more 
irritable  than  the  skin."  It  is  much  better  to  attempt  some  con- 
stitutional treatment  in  children  with  psoriasis  ;  by  changing 
their  nurses,  climate,  or  habitation ;  and  by  attending  to  cleanli- 


136  ON   THE    DISEASES    OP    INFANTS. 

ness,  together  with  the  prudent  adoption  of  such  measures  as  will 
meet  the  pathological  condition  of  the  digestive  organs. 

PITYRIASIS. 

Pityriasis  must  not  be  confounded  with  dandrif,  so  often  ob- 
served in  young  children.  It  consists  of  a  very  slight  inflam- 
mation of  the  skin,  accompanied  and  followed  by  a  furfuraceous 
exfoliation  of  the  epidermis.  It  may  be  seen  on  the  head  and  on 
different  parts  of  the  body.  It  is,  properly  speaking,  nothing 
more  than  a  termination  of  ery thematic,  erysipelatous,  or  lichenoid 
inflammation ;  and  I  am  surprised  that  pathologists,  and  Bate- 
man  in  particular,  have  described,  as  connected  with  this  species 
of  inflammation,  several  varieties  which  are  much  more  closely 
allied  to  other  diseases  than  to  that  now  under  consideration,  and 
with  which  they  have  nothing  in  common,  except  the  exfoliation 
of  the  epidermis. 

Pityriasis  occurs  on  the  head,  eyebrows,  arms,  trunk,  and  legs. 
The  cutaneous  inflammation  is  so  trifling,  that  it  ought  rather  to 
be  placed  among  the  alterations  of  the  epidermis,  than  among  in- 
flammations of  the  skin ;  and  I  only  place  it  here  in  accordance 
with  the  order  established  by  authors  whose  names  give  authority 
in  science.  Cleanliness  appears  to  me  all  that  is  necessary  in  the 
treatment  of  pityriasis,  at  least  when  it  is  not  caused  by  some 
more  serious  cutaneous  affection,  such  as  erysipelas  or  lichen. 

FISSURES — CHAFING. 

This  affection  is  developed  in  young  children  in  the  folds  of 
the  articulations,  especially  in  the  groin.  The  part  should  be 
sprinkled  with  powdered  lycopodium  or  starch.  Powders  of  the 
white  oxide  of  lead  should  be  avoided,  because,  as  Gardien  re- 
marks, children  may  experience  effects  analogous  to  painters' 
cholic.  Plenk  and  Professor  Chaussier,  have  made  similar  ob- 
servations. If  the  disorder  resist  the  usual  method  of  preserving 
cleanliness,  emollient  lotions,  and  the  application  of  the  powder 
spoken  of  above,  the  ointment  recommended  by  Rouen  may  then 
be  used : 

5«J  Cerati  simplicis,  ^ss. 
Pulveris  Lycopoclii, 
Oxidi  Zinci,  aa,  3j. 


ON   THE    DISEASES   OF    INFANTS.  137 

The  operation  of  this  ointment  may  change  the  chronic  and 
indolent  character  which  this  disease  sometimes  assumes. 

It  should  not  be  confounded  with  the  fissures  observed  on  tne 
body  during  the  exfoliation  of  the  epidermis. 

GANGRENE    OF    NEW-BORN    CHILDREN. 

By  the  term  gangrene  of  neiv-born  children,  I  understand  a 
variety  of  gangrenous  inflammations,  which  is  particularly  ob- 
served in  the  earlier  period  of  life,  in  those  infants  in  whom  the 
respiratory  and  circulatory  functions  are  imperfectly  executed, 
producing  a  very  evident  sanguineous  congestion  of  the  extremi- 
ties, which  become  purple  and  cold,  and  soon  shrink,  dry,  decom- 
pose, and  sphacelate,  until  an  inflammatory  circle  forming,  bounds 
the  ravages  of  the  gangrene,  analogous  to  the  gangrene  of  old 
people — or  until  death  terminates  this  disorganization  of  the  in- 
teguments. 

The  gangrene  ordinarily  commences  in  the  fingers  or  toes ; 
and  it  sometimes  shows  itself  on  the  arms  and  legs.  The  skin 
around  the  nails  assumes  a  violet  color,  and  tumefies  ;  afterwards 
it  shrinks,  wrinkles,  or  is  covered  with  small  blisters  containing  a 
sanguineous  fluid.  This  fluid  soon  flows  out,  and  a  livid  excori- 
ation appears  in  the  place  of  the  blisters  ;  the  integuments  become 
emphysematous  and  assume  a  brown  appearance,  diflusing  the 
well  known  gangrenous  odor.  During  this  time  the  child  is 
almost  without  motion,  is  insensible,  and  scarcely  respires  ;  the 
cry  is  smothered  and  plaintive,  and  he  gradually  sinks ;  the  ab- 
domen first  becoming  tympanitic,  and  the  different  parts  of  the 
body  osdematous,  while  scorbutic  petechiae  appear  upon  the  body 
and  limbs. 

Underwood  appears  to  have  confounded  this  gangrenous 
inflammation  with  erysipelas.  In  relation  to  this  latter  disease, 
he  observes :  "  In  a  few  instances  the  disease  has  been  attended 
with  some  varieties.  Infants  have  not  only  come  into  the  world 
withseveral  hard  inflammatory  patches,  and  ichorous  blisters  about 
the  thighs  and  belly,  but  with  other  spots  already  in  a  state  of 
mortification.  A  slough  soon  spreads  to  two  or  three  inches  in 
length  along  the  edges  of  the  skin,  with  smaller  ones  about  other 
parts  of  the  legs,  and  on  several  of  the  toes  and  fingers." 

I  believe  that  there  really  exists  a  difference  between  ordinary 

18 


138  ON   THE    DISEASES    IN    INFANTS. 

erysipelatous  inflammation  and  the  gangrene  of  the  skin,  which 
is  now  under  consideration.  In  this  case  it  is  not  by  excess  of 
inflammation  that  gangrene  occurs,  but  it  is  in  consequence  of  a 
great  disturbance  in  the  capillary  circulation,  and  to  the  retarded 
circulation  of  slightly  oxygenated  blood  in  the  subcutaneous  tis- 
sue, the  inevitable  result  of  which  is  a  shrinking  and  gangrenous 
degeneration  of  the  integuments. 

In  all  the  children  exhibiting  this  livid  color  of  the  extremities, 
this  cedematous  tumefaction,  together  with  this  spontaneous  gan- 
grene of  the  skin,  if  we  may  so  speak,  I  have  found  the  lungs 
crepitating  but  little,  but  they  were  always  gorged  with  blood, 
which  also  filled  the  right  cavities  of  the  heart,  and  the  whole 
venous  system ;  and,  penetrating  and  engorging  all  the  organs, 
produced  thereby  a  disposition  to  disorganization. 

The  object  in  the  treatment  ought  to  be  to  diminish  the  san- 
guineous congestion  by  the  application  of  leeches,  either  to  the 
arms  or  to  the  armpits,  and  to  promote  the  capillary  circulation 
by  the  use  of  dry  or  aromatic  frictions  to  the  surface  of  the  body. 
"When  the  gangrene  is  formed,  lotion  of  cinchona  wine,  or  Yir- 
ginia  snake-root,  ought  to  be  applied  to  the  ulcers  or  sloughs. 
But  what  efiicacy  can  we  expect  from  the  internal  administration 
of  cordials  in  young  children,  the  delicacy  and  irritability  ol 
whose  organs  naturally  centra-indicate  these  remedies,  and  whose 
stomaehs  are  very  often  either  actually  inflamed",  or  are  in  a  con- 
dition to  be  easily  excited  to  inflammation?  Underwood  men- 
tions that  Dr.  Wolsmon,  having  opened  the  bodies  of  two  children 
who  had  died  of  erysipelas,  found  the  membranes  of  the  stomach 
possessing  so  little  consistency,  that  the  least  effort  was  sufficient 
to  detach  some  portion. 

MALIGNANT  PUSTULE CARBUNCLE. 

Infants  at  the  breast  may,  without  doubt,  be  aflfected  with  ma- 
lignant pustule,  or  with  carbuncle ;  but  these  diseases  are  ex- 
tremely rare  at  this  period  of  life ;  should  they  occur,  they  ought 
to  be  met  by  the  usual  energetic  means  advised  in  such  cases. 

BURNS— CHILBLAINS. 

The  history  of  burns  and  chilblains  in  new-born  and  nursing 
infants,  requires  no  particular  consideration,  as  they  do  not  differ 


ON   THE  DISEASES   OP    INFANTS.  1S9 

from  the  same  affection  occurring  in  adults;  I  shall,  therefore, 
dispense  with  entering  on  the  examination  of  this  subject,  which 
can  be  found  in  all  works  of  general  pathology. 

DISEASES    OF   THE    APPENDAGES   OF   THE    SKIN. 

I  shall  here  speak  only  of  ichthyosis,  of  the  alterations  of  the 
cutaneous  follicles,  and  of  the  puriform  secretion  of  the  skin. 

Ichthyosis  is  an  affection  of  the  epidermis,  appearing  under  the 
form  of  patches  separated  from  each  other  by  irregular  lines  of 
little  depth.  These  epidermic  patches  are  generally  of  a  dirty 
gray ;  they  become  detached,  and  upon  separating,  leave  beneath 
them  the  epidermis  thickened  and  a  little  rough  to  the  touch. 
This  disease  is  usually  congenital.  It  lasts  sometimes  for  years, 
and  is  either  partial  or  general  in  its  extent. 

Ichthyosis  of  young  infants  ought  not  to  be  confounded  with 
the  epidermic  exfoliation  of  which  we  have  spoken,  and  which 
occurs  a  few  days  after  birth.  The  thickness  of  the  epidermic 
laminas,  their  continual  renewal,  the  persistence  of  the  disease 
beyond  the  ordinary  term  of  epidermic  exfoliation,  and,  finally, 
the  form  and  appearance  of  the  lamellae,  are  the  diagnostic  signs 
of  these  two  pathological  conditions.  The  treatment  of  ichthy- 
osis in  young  infants,  ought  to  consist  of  tepid  and  emollient 
baths,  gentle  frictions  with  oil  of  sweet  almonds  or  olive  oil,  aci- 
dulated drinks,  and  strict  attention  to  cleanliness.  Time  will  ef- 
fect more  in  the  cure  of  this  disease  than  remedies ;  still,  it  is  well 
known  that  it  often  continues-  for  a  very  long  time,  and  does  not 
disappear  even  in  advanced  age. 

Cutaneous  follicles. — The  follicles  of  the  skin  in  young  in- 
fants are  very  much  developed.  Their  disposition,  situation,  and 
their  relation  to  the  other  parts  of  the  skin,  have  been  well  de- 
scribed in  a  memoir  by  E.  H.  Weber,  inserted  in  the  number  of 
the  Journal  Complementaire  du  Dictionaire  des  Sciences  Medi- 
cales,  for  December,  1827.  These  follicles,  quite  prominent  on 
the  face  and  scrotum,  are  subject  to  engorgements  and  swelling, 
and  form  a  projection,  which  is  usually  black  in  the  centre,  de- 
nominated by  some  pathologists  "  crinonsT*  When  these  projec- 
tions are  pressed,  u  small  quantity  of  thickened  matter  issues,  of 

*  Gardien,  t.  4,  p.  135. 


140  ON  THE  DISEASES  OF    INFANTS. 

a  black  color,  which  may  be  taken  for  worms,  but  which  is  the 
result  of  the  disorganization  of  the  follicle.  This  disease,  gener- 
ally of  little  extent,  disappears  with  age,  and  requires  no  treat- 
ment. Yet,  if  there  exists  a  number  of  these  tumefied  follicles, 
as  they  often  cause  a  violent  itching,  it  would  be  well  to  apply 
emollient  lotions  to  the  skin,  and  to  extract  by  pressure,  or  by 
means  of  a  needle,  the  dead  cellular  substance  contained  in  the 
little  follicular  tumor. 

The  puriform  oozing  occurring  on  various  parts  of  the  skin  of 
children,  and  particularly  behind  the  ears,  is  an  alteration  in  the 
secretion  of  the  derma  ;  the  surface  of  which,  deprived  of  its 
epidermis,  continually  pours  out  a  fluid,  which  concretes  in  the 
form  of  yellow  scales.  This  discharge  is  usually  fovorable  to 
the  health  of  the  child ;  for  experience  has  shown,  that  when  it 
is  suddenly  suppressed,  the  most  serious  effects  will  often  follow, 
such  as  encephalitis,  ophthalmia,  etc.  In  the  treatment,  we  should 
confine  ourselves  to  the  preservation  of  cleanliness,  and  by  the 
application  of  linen  or  fine  lint,  or  the  leaves  of  the  white  beet. 

DISEASES    OF    THE    CELLULAR    TISSUE. 

The  diseases  of  the  cellular  tissue  are  divided  into  inflamma- 
tion, and  serous  infiltration.  It  may,  besides,  be  the  seat  of  san- 
guineous effusion,  or  of  infiltration,  either  at  the  parts  that  have 
been  compressed,  or  at  points  which  have  not  been  exposed  to 
pressure  ;  in  the  latter  case,  the  blood  is  found  effused  by  a  true 
sanguineous  exhalation,  a  phenomenon  of  very  common  occur- 
rence, as  we  shall  see  in  those  cases  where  respiration  and  circu- 
lation are  established  with  difficulty. 

Art.  1.— Inflammation  of  the  Cellular  Tissue. 

Phlegmon  and  anthrax  are  usually  seated  in  the  subcutaneous 
cellular  tissue  ;  the  former  is  of  common  occurrence  in  children 
at  the  breast.  It  sometimes  produces  an  extensive  destruction  of 
the  skin.  I  once  saw  an  infant,  aged  two  months  and  a  half,  in 
whom  the  lateral  portion  of  the  skin  of  the  right  breast  was  de- 
stroyed to  a  great  extent,  in  consequence  of  phlegmonous  inflam- 
mation causing  so  abundant  a  suppuration,  that  rapid  sinking 
and  death  were  the  consequence. 


ON   THE  DISEASES   OF    INFANTS.  141 

Indolent  abscesses  are  also  very  common  diseases  in  young 
children.  They  show  themselves  especially  on  the  limbs  ;  and 
when  they  ulcerate,  their  hard,  violet-colored,  and  undermined 
borders,  present  an  appearance  so  much  resembling  venereal  sores, 
that  they  have  often  been  regarded  as  such. 

Simple  antiphlogistic  treatment  for  acute  phlegmonous  abscess- 
es, the  use  of  slightly  stimulating  topical  applications,  gentle 
compression,  escharotics,  alkaline  or  aluminous  lotions  for  those 
that  are  chronic  and  indolent,  are  the  proper  remedies;  they 
should  be  used  with  great  precaution,  and  according  to  the  rules 
laid  down  in  surgical  works  on  the  subject  of  these  affections. 
It  should  be  particularly  noted,  whether  these  abscesses  are  not 
symptomatic  of  some  other  remote  disorder. 

(Edema  or  serous  inflammation  of  the  cellular  tissue  in  young 
infants,  deserves  to  be  studied  with  minute  attention  ;  we  shall, 
therefore,  devote  an  extended  space  to  its  history. 

Art.  2.— CEdema,  or  Induration  of  the  Cellular  Tissue  of  New-born 
Children. 

The  hard  or  indurated  state  in  which  a  child  is  sometimes 
found,  is  manifested  by  a  swelling  of  the  limbs  or  face,  which 
are  more  or  less  colored,  and  their  firm  resistance  to  the  touch, 
analogous  to  what  is  experienced  on  pressing  a  hard  and  com- 
pact body.  The  sensation,  therefore,  produced  by  touching, 
gave  rise  at  first  to  the  expression,  induration  of  the  cellular  tis- 
sue. Anatomical  examinations,  however,  have  proved  the  vague- 
ness of  such  expressions,  and  the  denomination,  compact  oedema, 
has  been  proposed  in  the  place  of  induration.  Some  physicians 
have  recently  observed,  that  induration  of  the  cellular  tissue  offers 
two  varieties  :  1st,  That  of  the  cellular  tissue,  properly  so  called ; 
2dly,  That  of  the  adipose  tissue,  (Duges,  Denis.)  In  the  esta- 
blishment of  this  variety,  there  is  an  evident  proof  of  the  progress 
of  our  knowledge  of  this  disease. 

According  to  Andry  and  Auvity,  from  the  cells  of  the  indurated 
cellular  tissue  a  large  quantity  of  sernm  escapes,  when  an  incision 
is  made  and  the  tumor  pressed.  But  if  we  fix  our  attention  on 
the  cellular  tissue,  properly  so  called,  besides  the  serum  with 
which  it  is  distended,  does  it  exhibit  a  hardness  resembling  that 


142  ON   THE    DISEASES    OP    INFANTS. 

of  sclerotic  or  schirrous  affections,  or  of  callous  tumors  ?  .  No ;.  on 
the  contrary,  it  preserves  all  its  elasticity,  suppleness  and  cel- 
lulosity  ;  its  fibres  have  not  undergone  any  organic  transforma- 
tion, but  still  preserve  their  reticulated  condition  ;  but  as  they  are 
considerably  distended  with  serum,  and  as  the  whole  cellular 
membrane  of  the  body  and  limbs  is  filled  with  fluid,  it  necessa- 
rily results  that  the  cellular  tissue  is  hard  to  the  touch ;  but  this 
hardness  does  not  really  exist  in  this  tissue,  which  has  undergone 
no  other  chanofe  than  that  of  mechanical  distension :  in  a  word- 
this  induration  has  no  existence  except  in  our  sensations.  The 
same  phenomenon  occurs  when  a  bladder  is  filled  with  water, 
mercury,  or  even  with  air.  If  it  be  completely  distended  with 
them,  it  offers  to  the  touch  a  hardness  in  which  its  tissue  has  no 
participation  ;  for,  if  one  third  or  one  half  of  the  substance  be  re- 
moved, the  bladder  then  becomes  soft  and  flaccid.  •  The  same  oc- 
curs in  the  induration  of  the  cellular  tissue  of  new-born  children. 
It  increases  in  hardness  in  proportion  to  the  accumulation  of  se- 
rum. 

Thus,  then,  strictly  speaking,  there  is  no  induration  of  the  cel- 
lular tissue  in  the  disease  designated  by  this  title.  Modern  au- 
thors who  have  retained  this  name,  are  certainly  to  be  blamed, 
and  much  more  those  who  have  proposed  that  of  "sclereme,"  to 
which  term  is  very  naturally  attached  the  idea  of  a  transforma- 
tion of  the  cellular  tissue,  which  does  not  really  exist. 

I  have  said  that  the  apparent  induration  of  the  limbs  of  a  foB- 
tus  may  be  seated  either  in  the  cellular  or  adipose  tissue.  When 
the  hardness  of  the  integuments  is  owing  to  a  serous  infiltration 
of  the  cellular  tissue,  the  limbs  are  swelled,  or  at  least  increased, 
in  size.  The  violet  color  of  the  integuments  indicates  a  sangui- 
neous congestion  of  those  parts  ;  the  irregularity  of  the  pulse,  and 
the  difficulty  of  respiration,  are  evident  signs  of  a  superabun- 
dance of  blood  in  the  heart,  lungs,  and  large  vessels. 

Induration  of  the  adipose  tissue  exists  with  or  without  gene- 
ral infiltration  of  the  siibcutaueous  cellular  tissue:. it  is  usually 
seated  in  the  cheeks,  nates,  calves,  or  back ;  and  occurs  both 
with  or  without  derangement  of  the  circulation  or  respiration. 
It  usually  appears  when  the  child  is  in  articiilo  mortis  ;  and  I 
have  often  seen  it  developed  after  death  on  the  dead  body  of 
children  tliat  had  suddenly  died.     If  the  adipose  tissue  be  then 


ON   THE    DISEASES    OF    INFANTS.  143 

examined,  it  will  be  found  firm  and  hard,  like  tallow,  and  entire- 
ly congealed;  resembling  the  fat  of  animals  killed  in  th'e  slaugh- 
ter-houses. It  can  be  easily  conceived  that  the  adipose  tissue 
may  also,  under  some  circumstances,  congeal  in  the  same  man- 
ner even  during  life,  if  from  some  cause  the  animal  heat  should 
cease  to  exist. 

Does  the  infiltration  of  the  cellular  tissue,  which  in  young  in- 
fants produces  the  apparent  induration  of  their  limbs,  differ  from 
that  which  sometimes  occurs  in  adults  ?  The  solution  of  this 
question  appears  to  me  of  much  importance. 

M.  Breschet,  regarding  this  oedema  as  peculiar  in  its  nature, 
has  had  recourse,  in  order  to  establish  the  truth,  to  the  assistance 
of  one  of  our  most  celebrated  chymists,  who  undertook  to  ascer- 
tain the  condition  of  the  serous  infiltrations  in  the  cellular  tissue 
of  children  thus  affected.  M.  Chevreul  gives  the  result  of  his 
experiments  in  the  following  language: 

■  "  I  have  already  established  the  fact,  that  in  the  icterous  affec- 
tion accompanying  the  induration  of  the  cellular  tissue  in  new- 
born children,  the  blood  is  diseased  ;  it  has  two  coloring  substan- 
ces not  found  in  the  blood  of  healthy  children,  or  if  they  are 
found,  are  in  very  small  quantities;  besides,  there  exists  also  an 
ingredient  which  imparts  to  the  serum  when  separated  from  the 
fibrin,  the  property  of  spontaneous  coagulation.  The  coloring 
principles  explain  the  color  of  the  cellular  tissue  ;  and  the  spon- 
taneously coagulable  matter  explains  the  induration  of  the  cellu- 
lar tissue,  if  it  were  demonstrated  that  this  matter  does  not  exist 
in  the  blood  of  healthy  children,  or  that  it  is  found  in  very  small 
quantities,  and  also  if  it  can  coagulate  in  the  cellular  tissue,  as  it 
coagulates  in  the  serum  drawn  from  the  bodies  of  those  children 
who  have  died  from  induration."* 

The  reading  of  this  paragraph  gave  rise  to  the  following  re- 
flections. M.  Breschet  has  considered  icterus  and  induration  of 
the  cellular  tissue  as  one  and  the  same  disease ;  he  has  only  pre- 
sented to  M.  Chevreul's  notice  such  infants  as  have  at  the  same 
time  been  affected  with  induration  and  icterus,  and  it  is  to  the 
yellow  serum  alone  that  this  chymist  has  particularly  directed 

*  Chevreul,  considerations  general  siir  V analyse  qrganique  et  sur  ses  appUeations. 
Paris,  1824,  p.  218. 


144  ON   THE    DISEASES   OF    INFANTS. 

his  attention.  There  also  exists,  in  the  language  of  M.  Chev- 
reul,  a  kind  of  uncertainty  or  philosophical  doubt,  arising  from 
the  severity  and  impartiality  of  his  judgment.  He  has  not  laid 
down  the  principle,  that  the  induration  of  the  cellular  tissue  is 
attributable  to  the  principle  of  spontaneous  coagulation  of  the 
serum ;  but  he  has  well  expressed  the  uncertainty  of  his  infer- 
ences by  observing  that  such  would  be  the  course  of  the  indura- 
tion, if  it  had  been  shown  that  this  matter  did  not  exist  in  the 
blood  of  healthy  children  ;  and  also  that  it  might  coagulate  in 
the  cellular  tissue,  as  it  coagulates  in  the  serum  drawn  from  the 
bodies  of  children  who  have  died  from  induration. 

General  infiltration  of  the  integuments  must  not  be  confound- 
ed with  icterus,  because  one  exists  without  the  other  ;  yet  both 
these  phenomena  also  may  exist  together.  The  serosity,  there- 
fore, must  be  considered  as  independent  of  the  coloring  matter 
which  it  sometimes  contains. 

I  placed  in  a  vessel,  as  M.  Chevreul  had  previously  done,  a 
small  quantity  of  serosity,  drawn  from  the  cellular  tissue  of  a 
child,  OBdematous  and  aifected  with  induration,  and  observed  that 
it  coagulated  spontaneously.  After  having  established  this  fact, 
I  was  desirous  of  ascertaining  whether  serosity  taken  from  the 
cellular  tissue  of  a  child  in  good  health,  would  likewise  coagu- 
late ;  the  same  phenomenon  occurred.  I  placed  in  two  differ- 
ent vessels,  serosity  taken  from  the  cellular  tissue  of  a  child  whose 
integuments  were  indurated,  and  from  one  in  whom  they  had 
undergone  no  change.  Coagulation  was  effected  in  both  in  near- 
ly the  same  time.  This  double  experiment  was  made  with  yel- 
low serum,  taken  from  an  icterous  subject,  and  on  the  same 
fluid  taken  from  one  not  so  affected ;  the  same  result  occurred 
in  both.  I  drew  the  serosity  from  the  cellular  tissue  of  the 
feet  of  a  child  a  year  old,  who  had  died  of  gastro-enteritis,  who 
was  reduced  to  marasmus,  and  whose  legs  alone  were  (Edema- 
tous ;  the  fluid,  after  remaining  at  rest  for  half  an  hour,  became 
thickened :  and  I  have  also  seen  the  serosity  taken  from  the 
dead  body  of  an  adult,  who  had  died  of  an  affection  of  the  heart, 
coagulate  at  the  end  of  six  hours.  Hence,  is  not  this  sponta- 
neous coagulation  an  inherent  property  of  the  fluid,  causing  the 
induration  of  the  cellular  tissue?     Consequently,  the  first  condi 


ON   THE    DISEASES    OF    INFANTS.  145 

tion  required  by  M.  Chevreul  for  the  explanation  of  the  indurat- 
ed state  of  the  cellular  tissue,  according  to  M.  Breschet's  theory, 
has  not  been  fulfilled.  Let  us  see  if  the  second  is  better,  or,  in 
other  words,  let  us  see  if  the  matter  of  the  spontaneous  coagula- 
tion of  the  serum,  can  coagulate  in  the  cellular  tissue. 

Heat  and  rest  hastened  the  coagulation  of  the  serosity  deposit- 
ed in  one  of  the  vessels.  If  the  liquid  already  thickened  were 
shaken,  it  soon  returned  to  its  fluid  state.  Now,  we  cannot  con- 
ceive of  the  serosity  being  in  such  a  state  of  immobility  in  the 
middle  of  the  cellular  tissue,  as  to  allow  of  its  coagulation  ;  on 
the  other  hand,  the  temperature  of  indurated  children  is  usually 
quite  low ;  consequently,  neither  immobility  nor  heat,  both  fa- 
vorable to  the  coagulation  of  serum  drawn  from  the  cellular  tis- 
sue, exist  in  the  cellular  tissue  of  young  infants. 

There  is  still  another  manner  of  proving  that  this  condensa- 
tion does  not  occur  in  the  cellular  tissue.  If  an  incision  be  made 
in  the  infiltrated  limbs  of  a  child,  the  slightest  pressure  will  cause 
abundant  drops  of  liquid  serosity  to  flow  out.  When  it  has  flow- 
ed in  this  manner,  the  cellular  tissue,  heretofore  engorged,  dis- 
tended, and  hardened,  returns  to  its  softened  condition,  and  the 
relieved  limbs  are  no  longer  hard.  I  repeated  this  experiment 
with  success  before  M.  Chevreul,  on  a  foetus  both  icterous  and 
indurated,  the  body  of  which  presented  all  the  characters  of  those 
on  which  this  celebrated  chymist  had  made  his  first  researches. 
Besides,  I  suspended  during  one  night,  by  the  head,  the  body  of 
an  indurated  infant,  making  a  number  of  incisions  in  the  legs. 
On  the  following  day  these  parts  were  covered  with  ser^xxii, 
which  flowed  from  the  incisions  and  appeared  on  the  limbs  like 
dew.  Now  the  serosity  could  in  no  way  have  obeyed  the  laws 
of  gravity,  and  would  not  have  flowed  thus  freely,  if  it  had  been 
conofealed  in  the  midst  of  the  cellular  tissue. 

It  results,  from  these  considerations,  and  from  the  preceding 
facts,  that  the  induration  of  the  cellular  tissue  of  young  infants, 
is  nothing  more  than  simple  oedema,  analogous  to  that  which  oc- 
curs in  adults  and  old  people  affected  with  diseases  of  the  lungs, 
heart,  and  large  vessels.  It  is  known  that  the  infiltrated  limbs 
sometimes  possess  a  hardness  equal  to  that  of  the  limbs  of  a 
young  infant.  The  redness  of  the  skin  in  children  depends  on 
the  constant  state  of  congestion  in  which  it  is  found 

19 


146  ON   THE    DISEASES   OF   INFANTS. 

It  remains  for  us  to  examine  what  are  the  causes  which  pro- 
duce oedema  in  young  children.  Authors  have  explained  them 
in  different  ways.  It  is  useless  to  consider  the  singular  idea  of 
Uzembezius,  that  the  sight  of  marble  statuary  might  influence 
mothers  during  pregnancy,  and  extend  to  their  offspring.  Neither 
shall  we  stop  to  consider  the  tanning  property  of  the  liquor  am- 
nil ;  but  it  is  of  greater  importance  to  consider  more  natural  ex- 
planations. 

Andry  and  Auvity  have  regarded  the  action  of  cold  as  one  of 
the  principal  causes  of  induration  of  young  infants  ;  this  agent 
interrupts  the  insensible  transpiration,  retards  the  circulation, 
and  condenses  the  mucous  and  serous  flu'ids  in  the  tissues.  We 
shall  see  of  what  degree  of  confidence  this  opinion  is  worthy. 
M.  Troccon  has  controverted  it,  and  has  asserted  that  cold  usual- 
ly has  the  effect  of  increasing  instead  of  retarding  the  circulation. 
Most  authors,  and  Hulme  in  particular,  have  insisted  on  the  co- 
existence of  a  state  of  congestion  or  inflammation  of  the  lungs, 
with  induration  of  the  cellular  tissue,  and  have  pointed  out  in 
this  case  the  passive  congestion  of  the  heart  and  large  vessels. 
Underwood  has  vaguely  ascribed  it  to  the  influence  of  unhealthy 
air ;  whilst  Baumes  attributes  the  induration  to  the  rigidity  of 
the  muscles,  considering  an  attendant  symptom  as  the  end  of  the 
disease.  Palletta  ascribes  this  disease  in  part  to  the  agency  of 
the  liver.  Breschet  regards  it  as  the  result  of  an  accumulation 
of  serum  separated  from  the  blood,  and  as  a  disease  dependent  on 
the  imperfect  closure  of  the  foramen  ovale.  Leger  appears  dis- 
posed to  admit,  as  one  of  the  causes  of  the  induration,  the  slight 
development  of  the  intestinal  canal,  which  is  about  three  feet  or 
less  in  length,  in  children  with  this  disease.  M.  Denis,  who  has 
attached  extraordinary  importance  to  this  disease,  has  gone  still 
farther  than  his  predecessors  in  search  of  its  cause,  for  he  regards 
it  as  true  phlegmasia,  a  sympathetic  and  consecutive  irritation  of 
the  gastro-intestinal  apparatus,  which  he  calls  '•'' phlegmasie  eji- 
tero-cellulairey  I  cannot  assent  to  this  notion,  and  he  has  ex- 
posed himself  to  the  charge  of  having  made  a  forced  application 
of  the  principles  of  the  new  medical  doctrines.  Lastly,  M.  Ba- 
ron has,  for  a  long  time,  regarded  it  as  an  oedema, — a  simple  se- 
rous infiltration  of  the  cellular  tissue,  and  symptomatic  of  a  de- 
rangement or  obstruction  either  in  the  heart,  lungs,  or  large  vessels. 


ON   THE    DISEASES    OF    INFANTS.  147 

Such  are  the  most  remarkable  opinions  which  have  been  en- 
tertained with  reference  to  the  causes  of  the  induration  of  the 
cellular  tissue.  I  shall  now  submit  them  to  the  test  of  experi- 
ment. I  shall  report  and  comment  on  a  number  of  facts,  from 
the  study  of  which  T  will  draw  conclusions  which  may  enable  us 
to  decide  what  are  the  proper  causes,  and  what  the  nature  and 
treatment  of  this  affection.  It  is  the  only  method  of  clearing  up 
an  obscure  subject ;  for  in  a  science  of  observation,  man  ought,  if  I 
may  be  allowed  the  expression,-  to  conceal  himself  behind  the 
facts  which  alone  give  force  to  his  opinions  and  guaranty  their 
correctness. 

In  the  year  1826,  there  entered  the  Hospice  des  Enfans  Trou- 
ves  of  Paris,  5,392  children  ;  1404  of  this  number  died  either  in 
the  surgical  or  medical  infirmary,  or  at  the  "  Creche  ;"*  in  the 
medical  infirmary  under  the  care  of  M.  Baron,  777  were  received. 
The  number  of  children  affected  with  oedema,  or  induration  of 
the  cellular  tissue,  either  in  the  medical  infirmary  or  at  the 
"  Creche,"  was  240.  This  number  will  be  found  divided  as  fol- 
lows, according  to  the  different  months  in  the  year ;  the  number 
of  patients  in  the  infirmary  was  always  from  30  to  32. 

January,            15 

February,         15 

March,          16 

April, 18 

May,       22 

June, 3 

July,        4 

August,        14 

September, 10 

October,       16 

November, 29 

December,        15 

Indurated  children  not  treated  in  the  infirmary,  63 

Total  240 

According  to  this  statement,  it  is  evident  that  oedema  does  not 

*  This  name  is  given  to  the  apartment  where  infants  are  deposited  on  their  arrival. 


148  ON   THE    DISEASES    OF    INFANTS. 

affect  young  infants  only  during  the  winter ;  consequently 
the  explanation  given  by  Auvity  of  this  disease,  that  it  is  the 
result  of  the  condensation  of  the  serous  fluid  by  cold,  is  invali- 
dated by  the  exposition  just  given.  If  we  compare  the  entire 
number  of  infants  affected  with  induration,  or  oedema,  during  the 
summer  months,  with  the  number  attacked  with  it  in  the  winter^ 
it  will  be  seen  that  the  difference  does  no  amount  to  one  half,  and 
that  but  a  single  inference  can  be  drawn  from  this  calculation, — 
that  is,  that  the  disease  is  more  frequent  in  winter  than  in  sum- 
mer ;  thus,  during  the  months  of  January,  February,  November, 
and  December,  seventy-four  indurated  or  oedematous  infants  en- 
tered the  infirmary,  and  forty-three  during  the  months  of  May, 
June,  July,  and  August.  Let  us  add  to  the  preceding  remarks, 
that  diseases  are,  in  general,  more  frequent  in  winter  than  in  sum- 
mer, and  consequently  it  is  not  surprising  that  the  induration  of 
the  cellular  tissue  is  more  often  manifested  in  the  one  season  ra- 
ther than  in  the  other. 

Before  endeavoring  to  ascertain  what  are  the  organs  most 
often  affected  during  the  existence  of  this  disease,  or  after  its 
cessation,  let  us  study  it  with  reference  to  its  seat,  its  invasion, 
and  its  progress. 

Almost  all  the  children  that  are  the  subjects  of  these  remarks, 
were  of  the  age  of  one  to  eight  days ;  some  were  just  born,  and 
appeared  to  have  brought  this  disease  with  them  from  the 
womb.  This  fact  has  also  been  mentioned  by  those  physicians 
who  have  written  on  this  subject.  In  almost  all,  the  skin  still 
retained  the  peculiar  red  color  of  new-born  children.  In  nearly 
all,  the  epidermic  exfoliation  had  not  commenced,  or  had  but 
just  commenced  at  the  time  of  the  development  of  oedema.  The 
oedematous  disease  was  not  present  in  the  same  degree  in  all  the 
subjects  ;  the  induration  appeared  successively  on  the  feet,  hands, 
limbs,  pubic  region,  back,  and  face,  of  some ;  while  every  part 
of  the  body  was  affected  in  others,  in  a  very  violent  degree.  It 
is  extremely  common  to  meet  local  induration  or  oedema.  I  have 
several  times  seen  this  affection  develop  itself  some  days  after 
admission  to  the  infirmary.  The  induration  of  the  adipose  tis- 
sue is  sometimes  united  with  oedema  of  the  cellular  tissue; 
most  generally  the  first  exists  without  the  second.  The  progress 
of  the  disease  is  very  irregular ;  it  presents  no  fijced  period ; — no 


ON    THE    DISEASES    OP    INFANTS. 


149 


particular  phenomenon  announces  its  resolution  ;  audits  degrees 
of  intensity,  the  only  phenomenon  worthy  of  observatJn,  offer  in 
their  progress  and  in  their  decrease,  the  greatest,  but,  t  the  same 
time,  the  least,  appreciable  variety.  In  genera;l  oedeia,  the  se- 
rum is  not  only  infiltrated  through  the  cellular  tissue,i)ut  is  also 
effused  in  other  parts  of  the  body.  I  have  often  metwith  it  in 
the  sub-peritoneal  cellular  tissue,  in  the  cavity  of  the  mediasti- 
num and  in  the  plexus  choroides. 

Of  all  the  phenomena  accompanying  osdema  of  infats,  icterus 
is  one  of  the  most  common.  In  seventy-seven  infants  afected  with 
oedema,  I  observed  thirty  with  jaundice ;  but  did  not  tid  among 
them  any  organic  lesion  that  could  account  for  this  diftrence.  I 
shall  not  extend  my  observations  to  the  causes  whicl  appear  to 
produce  jaundice  in  young  infants,  this  being  an  inciqntal  ques- 
tion deserving  more  particular  consideration ;  let  it  siiice  to  re- 
mark, that  one  of  these  diseases  may  exist  without  the  ther  ;  that 
it  is  neither  the  cause  nor  effect  of  the  other,  and  cdsequently 
they  ought  not  to  be  placed  together  in  nosological  arrangement. 

It  is  important  to  know  how  far  hepatic  derangemets  may  in- 
fluence the  production  of  oedema;  the  following  exliMts  the  re- 
sult of  my  observations  on  this  subject.  In  ninety  indurated 
children,  on  a  post  mortem  examination  made  withgreat  care, 
the  liver  exhibited  no  alteration,  except  in  twenty  instances ; 
there  were  ten  with  considerable  sanguineous  conge^on  of  this 
organ  :  the  blood  with  which  it  was  filled  was  foun(J  black  and 
fluid ;  the  large  abdominal  vessels  were  equally  enorged,  and 
the  body  itself  was  in  a  state  of  general  congestion,  tn  fine,  the 
liver  was  friable  and  very  much  engorged  ;  the  bile  tjick  and  al- 
most concrete.  In  four  others,  the  liver  was  of  ajslate  color, 
firm,  and  resisted  the  cutting  of  the  scalpel ;  and  in  tfe  last  of  the 
number,  there  existed  peritonitis,  a  congestion  of  tb  liver,  and 
a  sero-sanguinolent  effusion  in  the  abdomen.  It  caiiot  be  infer- 
red from  these  facts  that  the  sanguineous  congestionthe  friabili- 
ty or  inflammation  of  the  peritoneal  coat,  or  even  o^the  liver  it- 
self, are  the  ordinary  causes  of  oedema  of  the  celluU  tissue ;  for 
I  have  met  with  a  great  number  of  children  presenlng  these  al- 
terations in  whom  induration  did  not  exist,  and  iiany  others 
where  the  cellular  tissue  was  infiltrated  with  seroaty,  in  whom 


150  ON   THE    DISEASES    OF    INFANTS. 

the  post  lortem  examination  did  not  result  in  the  discovery  of 
the  altenion  I  have  pointed  out. 

Infllannation  or  congestion  of  the  lungs  has  been  regarded  as 
a  cause  f  the  affection  which  we  are  now  considering;  and 
wishing  t  ascertain,  by  facts,  the  truth  of  this  assertion,  I  examin- 
ed the  stte  of  the  lungs  in  the  seventy-seven  oedematous  infants 
already  lentioned  while  speaking  of  icterus  :  in  forty-three  of 
these,  thdungs  were  perfectly  sound;  the  remaining  thirty-four 
presentee  the  respiratory  apparatus  in  a  pathological  condition 
more  or  jss  serious.  In  twelve  of  these,  there  existed  a  pulmo- 
nary congestion  ;  in  six,  complete  hepatization,  four  of  them  in 
the  rightand  two  in  the  left  lung ;  in  three,  there  was  pleuro- 
pneumora,  and  in  the  others,  simple  passive  congestion  at  the 
posterior3orders  of  the  lungs,  and  particularly  in  the  right  lung. 
It  is  suffiient  that  there  exist  examples  of  induration  or  cEdema 
of  the  cdular  tissue  of  young  infants,  without  pneumonia  or 
pulmona'y  congestion,  to  be  satisfied  of  the  little  influence  that 
the  latteriisease  exercises  in  the  production  of  serous  infiltra- 
tion of  t^e  cellular  tissue,  and  to  make  us  call  in  question  the 
truth  of  I.  Hulme's  assertion. 

I  shall  low  examine  the  opinion  of  M.  Breschet,  who  regards 
the  induution  of  the  cellular  tissue  as  depending  upon  the  con- 
tinuation )f  the  foramen  ovale.  In  seventy-seven  children  men- 
tioned ab  ve,  forty  presented  the  foramen  completely  closed  ;  in 
twenty-eiht  of  these,  the  ductus  arteriosis  was  considerably 
narrowed  and  the  blood  could  not  pass  through  it.  The  theory 
of  M.  Brechet,  therefore,  falls  before  the  evidence  of  these  facts. 
If  the  formen  ovale  be  found  still  open  in  indurated  infants,  it 
is,  that  insmuch  as  induration  of  the  cellular  tissue  affects  parti- 
cularly vry  young  infants,  the  changes  which  take  place  in 
the  heart  ad  ductus  arteriosis  of  new-born  children,  after  the  es- 
tablishmer  of  the  independent  circulation,  have  not  had  time  to 
occur  befo3  the  development  of  oedema.  I  believe,  therefore, 
that  there  (xists  no  relation  between  these  two  phenomena. 

I  have  a50  measured  the  intestines,  to  ascertain  the  correctness 
of  the  fact  dvanced  by  M.  Theodore  Leger,  who  found  them  in 
children  aflicted  with  this  disease  much  shorter  than  in  others. 
I  have  obseved  nothing  that  has  any  resemblance  of  the  fact, 


ON    THE    DISEASES    OP    INFANTS.  151 

either  because  I  may  have  carelessly  conducted  my  ohervations, 
or  that  chance,  which  seems  to  have  aided  M.  Leger,  as  not  led 
me  to  the  same  result.  Besides,  this  point  in  the  his>ry  of  the 
induration  of  the  cellular  tissue  appears  to  me  of  little  iiportance, 
for  it  is  difficult  to  conceive  what  relation  of  cause  and3ffect  can 
exist  between  these  two  states  of  organization. 

If  our  opinions  are  to  be  supported  only  by  the  nmber  of 
facts,  and  if  we  are  not  to  avail  ourselves  of  the  advatages  af- 
forded by  our  judgment  and  experience,  in  commenting  on  these 
facts,  I  should  be  inclined  to  think,  with  M.  Denis,  that  ne  of  the 
most  common  affections  that  accompany  induration  of  le  cellu- 
lar tissue  is  gastro-enteritis,  and  to  admit  the  union  whia  he  has 
attempted  to  establish  between  these  two  diseases.  Bu  as  Mor- 
gagni  has  said,  neque  enim  numerandce  sunt,  sed  perfndendce. 
ohservationes  ;  we  ought  not  to  stop  solely  upon  ascertaiing  the 
number  of  facts,  we  ought  to  weigh  them  and  duly  apreciate 
them,  that  no  forced  inferences  may  be  drawn,  nor  ay  false 
principles  established.  In  the  seventy-seven  cases  menoned  as 
the  subjects  of  examination,  there  were  fifty  with  inflamration  of 
the  alimentary  canal  to  greater  or  less  extent.  But  it  sbuld  be 
recollected  that  diseases  of  the  organs  of  digestion  are  muh  more 
frequent  in  young  infants  than  any  other  disease  ;  tha  in  the 
Hospice  des  Enfans  Trouves,  most  of  the  children  die  f  those 
inflammations,  and  that  the  induration  or  oedema  of  le  cel- 
lular tissue  may  exist  without  the  concomitance  of  an  inumma- 
tion  of  the  digestive  passages.  It  should  also  be  remembejd  that 
the  induration  of  the  cellular  tissue  is  of  more  frequenOccur- 
rence  in  winter  than  in  summer,  at  which  season  the  pbgma- 
siaj  of  the  alimentary  canal  are  more  rare ;  but  they  occu  more 
commonly  in  summer,  when  the  induration  of  the  cellulatissue 
is  less  frequent.  These  considerations  are  sufficient  to  pvent 
us  from  attaching  to  the  co-existence  of  these  two  kinds  ofiffec- 
tions,  all  the  importance  accorded  to  them  by  M.  Denis. 

In  the  last  place,  what  is  of  more  importance  to  note,  i;  that 
almost  all  the  indurated  oroBdematous  children  exhibit  auiver- 
sal  sanguineous  congestion,  that  is  very  remarkable.  Yaous 
blood  especially,  predominates  in  their  tissues  ;  the  heart  5  al- 
most always  gorged  with  blood,  and  the  large  vessels  fiUedand 
when  the  bodies  of  those  who  have  died  of  this  disease  ar  ex- 


152 


ON   THE    DISEASES   OF    INFANTS. 


amined,  itpows  from  all  parts  on  the  incision  of  the  scalpel. 
This  geniil  congestion  is  more  owing  to  a  superabundance  of 
blood  in  tfe  system,  to  a  kind  of  congenital  plethora,  rather  than 
to  any  mehanical  obstruction  in  the  blood  vessels.  Again :  the 
skin  is  riiarkable  for  its  extraordinary  dryness ;  no  moisture 
appears  t^  transpire  on  its  surface ;  it  is  arid  and  tense,  bearing 
the  evidetes  of  great  disturbance  in  the  capillary  circulation, 
and  that  ^e  cellular  tissue,  which  physiologists  tell  us  is  the  seat 
of  the  vjy  abundant  secretion  of  perspirable  matter,  is  clogged 
in  the  exTcise  of  its  proper  functions.  In  the  first  place,  the  ma- 
terials fouts  secretion  have  come  to  it  in  great  abundance,  since 
the  who!  of  the  tissues  are  engorged  with  blood ;  and  in  the  se- 
cond pla|3,  the  state  of  dryness  of  the  skin,  the  suspension  of  cu- 
taneous tanspiration,  and  perhaps  that  also  of  the  pulmonary 
transpir^on,  prevent  the  free  flow  of  the  secretion,  which,  re- 
mainingn  the  same  cells  which  produced  it,  causes  the  oedema 
that  hag-eceived  the  name  of  induration  of  the  cellular  tissue. 
There  ijone  circumstance  which  goes  to  support  the  opinion  we 
have  aqanced,  relative  to  the  effect  of  the  suspension  of  cuta- 
neous tinspiration  on  the  passive  infiltration  of  the  cellular  tis- 
sue ;  itis,  that  irritating  frictions  of  the  skin,  such  as  campho- 
rated ojof  chamomile,  will  cause  rapid  disappearance  of  the  OBde- 
ma ;  afl  when  the  child  is  wrapped  in  warm  woollen  applied 
to  thefkin,  it  is  surprising  to  find  it  on  the  succeeding  day 
bathedjn  sweat,  which  sometimes  rises  in  a  thick  vapor,  and  to 
see  thi  disappearance,  at  the  same  time,  of  the  induration  to  a 
greatejor  less  extent.  To  conclude:  it  cannot  be  admitted,  I 
think,(-s  is  asserted  by  M.  Denis,  that  the  disease  now  under 
consicration  is  a  phlegmasiss  of  the  cellular  tissue,  for  inflam- 
matio  of  this  tissue  gives  rise  to  a  very  quick  and  abundant  se- 
cretioj  of  pus,  possessing  peculiar  properties ;  and  nothing  of 
this  Ijid  appears  in  the  limbs  of  osdematous  children,  which  are 
not  uLially  the  seat  of  phlegmonous  tumors. 

Gkeral  conclusions -In  following  the  analytic  method  in  the 
stud^f  the  phenomena  of  life,  in  accordance  with  the  advice  of 
the  (Jlebrated  Pinel,  we  believe  that  the  following  truths  have 
beerjjstablished. 

li  The  induration  of  the  cellular  tissue  in  young  infants,  is 
notljng  else  than  simple  oedema,  analogous  to  the  oedema  of 


ON   THE    DISEASES    OF    INFANTS.  153 

adults.     It  may  be  either  local  or  general :  it  sliould  always  be 
distinguished  from  induration  of  the  adipose  tissue. 

2dly.  This  disease  is  more  common  in  winter  than  in  summer, 
and  more  frequent  in  young  infants  than  in  those  of  more  ad- 
vanced age.  The  predisposing  causes  are — 1st,  The  natural 
feebleness  of  the  child  ;  2dly,  A  state  of  general  and  congenital 
plethora  ;  3dly,  A  superabundance  of  venous  blood  in  the  tissues ; 
4thly,  A  dry  state  of  the  skin  before  the  exfoliation  of  the  epider- 
mis. The  immediate  causes  are — 1st,  An  obstruction  in  the 
course  of  the  blood,  resulting  from  its  quantity  in  the  circulato- 
ry apparatus ;  2dly,  Its  engorgement  in  the  cellular  tissue,  to 
which  it  furnishes  too  much  materials  for  secretion ;  3dly,  and 
lastly,  The  action  of  external  agents  on  the  skin,  which,  without 
condensing  the  serous  fluid,  as  has  been  asserted,  are  yet  capable 
of  suspending  the  cutaneous  transpiration,  and  thus  favor  the  ac- 
cumulation of  serosity  in  the  cellular  tissue.  The  sanguineous 
engorgement  of  the  liver,  lungs,  and  heart,  the  persistence  or 
closure  of  the  foetal  openings,  are  not  the  exclusive  and  indispen- 
sable causes  of  this  affection  ;  they  ought  not  to  be  considered  as 
concomitant  phenomena,  and  as  accessory  circumstances  to  a 
disease  which  may  exist  without  them,  and  which  is  often  ob- 
served to  be  the  case  in  local  oedema  or  induration. 

3dly.  When  oedema  is  general,  and  the  serous  congestion  is 
carried  to  a  high  degree,  all  parts  where  there  exists  cellular  tis- 
sue undergo  a  disturbance  in  the  functions  which  they  dis- 
charge. Thus,  the  glottis  becoming  oedematous  at  the  same  time 
that  the  lungs  are  the  seat  of  congestion,  the  cry  of  the  child  is 
generally  painful,  acute,  and  smothered.  The  slowness  of  the 
circulation  easily  explains  the  coldness  of  the  limbs,  and  the 
state  of  debility  into  which  the  patient  falls.  In  this  manner  all 
the  symptoms  described  by  authors  may  be  explained. 

4thly.  The  therapeutic  indications  pointed  out  by  these  con- 
siderations are — 1st,  To  relieve,  by  suitable  evacuations,  the  gene- 
ral plethora ;  2dly,  To  excite  the  skin  by  irritating  frictions,  by 
the  use  of  woollen  garments  next  to  the  skin,  and  the  adoption  of 
all  means  proper  to  establish  cutaneous  transpiration.  Vapor 
baths,  for  the  administration  of  which  M.  Peligot  has  constructed 
a  very  ingenious  apparatus  at  the  Hospice  des  Enfans  Trouves. 
has  not,  according  to  the  experience  of  M.  Baron,  so  good  an  ef- 

20 


154  ON    THE    DISEASES   OP    INFANTS. 

feet  as  frictions,  and  the  application  of  woollen  to  the  skin»  I 
have  often  seen  the  latter  succeed  perfectly.  The  respiration  of 
a  child  during  its  continuance  in  the  bath  is  painfully  accelerat- 
ed, and  congestion  and  effusion  on  the  lungs  or  brain  have  been 
seen  to  follow  the  use  of  these  baths. 

Such  are  the  conclusions  which  naturally  flow  from  the  con- 
sideration of  the  facts  contained  in  this  chapter.  I  have  not,  as 
will  be  seen,  attempted  to  overthrow  altogether  any  particular 
theory  of  those  authors  who  have  written  on  this  subject ;  but 
have  approved  or  controverted  each,  as  they  appeared  to  me  to 
be  either  correct  or  otherwise.  It  is  not  by  destroying  exclusive 
theories  and  replacing  them  with  others  not  less  exclusive,  that 
the  edifice  of  science  is  to  be  perfected,  but  rather  by  establishing 
the  facts  by  analysis,  and  gathering  the  results  of  the  observations 
of  all  men  and  all  times. 

I  shall  finish  my  remarks  on  this  subject  by  mentioning  a  fact 
worthy  of  notice.  The  great  mortality  of  the  Hospice  des  En- 
fans  Trouves  has,  for  a  long  time,  been  attributed  to  induration 
of  the  cellular  tissue.  This,  I  believe,  is  incorrect.  There  often 
exist  at  the  same  time  affections  of  the  brain,  lungs,  and  intestinal 
canal,  much  more  serious  than  cEdema,  and  much  more  fatal  to 
children.  The  number  of  those  who  really  died  of  oedema  or 
induration  of  the  cellular  tissue,  that  is  to  say,  in  that  state  of  ple- 
thora and  general  congestion  which  I  have  described,  without 
the  existence  of  serious  lesions  of  some  of  the  organs  at  the  same 
time,  amounted  in  1826  to  fifty.  The  following  is  an  extract 
from  the  register  of  deaths  in  the  hospital: 

January,        .        .        8        July,         .        .        .0 


February, 

2 

August,     . 

.    2 

March,  . 

4 

September, 

.    2 

April,     . 

8 

October,    . 

.    3 

May,      . 

.      13 

November, 

.    0 

June,     . 

4 

December, 

.    4 

It  was  in  the  months  of  May  and  November  that  the  greatest 
number  affected  with  induration,  were  admitted.  All  these  pa- 
tients, in  the  latter  month  particularly,  died  of  affections  of  some 
important  organ,  and  more  frequently  of  that  of  the  lungs,  rather 
than  of  induration  of  the  cellular  substance. 

When  oedema  is  local,  or  if  it  be  general  and  yet  not  severe,  it 


ON    THE    DISEASES    OP    INFANTS.  155 

is  not  to  be  regarded  as  a  fatal  disease  ;  nor  will  it  become  so  un- 
less complicated  with  some  affection  seated  on  an  organ  essential 
to  life. 


CHAPTER    II. 

DISEASES   OF    THE    DIGESTIVE    APPARATUS. 

1  HAVE  adopted  the  division  of  the  alimentary  canal  proposed 
by  Meckel,  who  considers  it  as  consisting  of  the  cephahc,  tho- 
racic, and  abdominal  or  subdiaphragmatic  portions. 

The  cephalic  portion  comprehends  the  mouth  and  its  appenda- 
ges. I  shall,  in  the  first  place,  consider  the  form  and  aspect 
which  they  present  in  a  state  of  health,  both  during  intra-uterine 
life,  as  well  as  after  birth. 

The  buccal  cavity  is  very  small  at  the  first  period  of  foetal  ex- 
istence ;  it  is  not  until  about  two  months  that  it  deserves  the 
name  of  a  cavity,  and  it  is  then  almost  entirely  filled  with  the 
tongue ;  and  the  motions  of  the  lower  jaw  are  so  limited,  that  I 
doubt  whether,  at  this  period,  there  could  be  any  motions  exer- 
cised analogous  to  those  of  deglutition.  The  color  of  the  mem- 
brane lining  the  mouth,  and  that  of  the  tongue,  does  not  present 
any  thing  remarkable  until  about  the  sixth  month ;  but  at  this 
time,  and  to  the  seventh,  eighth,  and  ninth  month,  it  deserves 
some  notice.  It  may  be  more  or  less  colored,  and  more  or  less  in- 
jected, agreeing  with  the  general  condition  of  the  foetus ;  for  in 
three  individuals  of  this  age  whom  I  dissected,  it  was  in  one  of  a 
violet  red,  and  in  the  other  two  pale  red.  From  the  seventh  to 
the  ninth  month,  the  color  of  the  buccal  membrane  is  generally 
of  a  deep  rose ;  the  papillae  at  the  extremity  of  the  tongue  are 
more  projecting,  but  those  at  its  base  better  delineated  and  more 
prominent ;  the  pjllars  of  the  velum,  and  the  velum  palati  itself, 
present  the  arrangements  of  the  parts  which  they  afterwards  have, 
and  the  distance  with  which  they  are  separated  from  the  exter- 
nal opening  of  the  mouth,  is  evidently  increased.  And  again : 
the  lateral  parietes  of  this  cavity  are  separated,  and  the  lower 


156  ON  THE  DISEASES  OP  INFANTS. 

jaw  has  become  more  moveable,  so  that  at  the  sixth  to  the  eighth 
month,  the  buccal  cavity  becoming  larger,  and  the  lower  jaw  ad- 
mitting of  more  motion,  it  is  possible  that  the  child  may  execute 
some  movement  analogous  to  mastication  or  deglutition  ;  this  is 
indeed  what  really  occurs,  if  we  may  judge  from  analogy  and 
from  the  observations  made  on  quadrupeds  by  Haller,  and  subse- 
quently by  Beclard. 

At  the  period  of  birth,  the  buccal  membrane  is  usually  very 
red ;  it  is  the  same  with  the  tongue  and  gums ;  all  these  parts 
are  congested  with  blood  analogous  to  that  of  the  external  inte- 
guments ;  they  might  be  pronounced  inflamed  on  a  superficial 
inspection,  but  against  such  an  error  we  should  be  carefully 
guarded.  They  gradually  lose  this  deep  color,  and  soon  acquire 
that  of  the  rose,  which  is,  for  the  most  part,  the  color  of  the  skin ; 
for  in  children  whose  integuments  are  very  pale,  the  buccal  mem- 
brane, if  it  be  not  inflamed,  is  itself  but  faintly  colored. 

The  salivary  glands  are  scarcely  visible  during  two-thirds  of 
the  foetal  life  ;  it  is  only  towards  the  seventh  month  of  gestation 
that  they  acquire  any  size.  At  first  they  consist  of  a  few  granula- 
tions which  are  blended  with  the  cellular  tissue  ;  but  at  seven  to 
nine  months  they  agglomerate,  and  assume  their  proper  form. 
Their  excretory  ducts  open  into  the  buccal  cavity  by  a  hole  al- 
most imperceptible.  The  sublingual  gland  appears  to  me  to  be 
developed  the  first,  then  the  submaxillary,  and  lastly  the  parotid. 

At  birth  these  glands  are  scarcely  formed  ;  but  they  are  devel- 
oped with  great  activity,  and  towards  the  seventh  month,  that 
is,  when  the  incisor  teeth  appear,  the  sublingual  and  parotid 
glands  are  considerably  augmented  in  size  and  furnish  an  abun- 
dant secretion.  It  appears  as  if  their  development  and  function- 
al activity  are  more  perfect  in  proportion  as  the  mouth,  and  espe- 
cially the  gums,  require  to  be  moistened  and  softened. 

Section  I. 

DISEASES    OP   THE    MOUTH. 

H.  Congenital  MALFORMATIONS. — Absence  of  the  mouth. — 
The  malformations  of  the  mouth  and  those  of  the  face  in  ge- 
neral have  been  described  with  great  care  by  M.  Larocheof 


ON    THE    DISEASES    OF    INFANTS.  157 

Angers,  in  his  excellent  inaugural  dissertation.*  This  author 
correctly  distinguishes  between  the  complete  absence  of  the  mouth 
and  the  obliteration  of  its  anterior  orifice. 

The  absence  of  the  buccal  cavity  is  called  astomia  ( a  arojia^ 
and  the  obliteration  of  the  anterior  orifice,  atresia  of  the  mouth. 

The  absence  of  the  buccal  cavity  occurs  when  the  bones  of 
the  face  have  been  arrested  in  their  development,  and  particular- 
ly when  the  lower  jaw  is  wanting.  This  deformity  cannot  be 
remedied,  and  the  child  affected  with  it  soon  dies.  Sometimes, 
M.  Laroche  observes,  in  the  place  of  a  mouth  an  irregular  open- 
ing is  found,  although  situated  lower,  and  communicating  with 
the  larynx  and  oesophagus.  Borichius  has  seen  instead  of  the 
mouth,  a  hole  in  the  right  cheek. 

In  a  very  young  embryo,  five  or  six  weeks  old,  for  instance, 
the  mouth  is  not  closed,  properly  speaking ;  but  the  two  lips  are 
so  closely  approximated,  and  the  labial  orifice  so  narrow,  that 
one  can  hardly  be  led  to  believe  that  an  orifice  exists.  Yet  the 
contrary  may  be  easily  ascertained  by  separating  the  lips  with  the 
point  of  a  needle.  The  buccal  cavity  may  then  be  easily  distin- 
guished, entirely  filled  with  the  tongue,  which  extends  to  the 
borders  of  the  lips.  In  the  natural  state,  this  opening  gradually 
enlarges,  the  borders  of  the  lips  cease  to  be  contiguous ;  at 
about  four  months,  the  comissures  are  found  to  be  on  each  side, 
on  a  line  drawn  perpendicularly  from  the  middle  of  the  eye- 
brows. Finally,  at  six,  seven,  and  nine  months,  this  opening  ac- 
quires a  diameter  corresponding  in  size  to  the  other  parts  of  the 
head. 

Obliteration  of  the  mouth, — It  sometimes  happens  that  the 
borders  of  the  lips,  irritated  and  inflamed  at  some  period  of  the 
intra-uterine  life,  contract  and  adhere  either  in  a  part  or  in 
the  whole  of  their  extent,  and  we  can  conceive,  from  this,  the 
possibility  of  an  incomplete  or  complete  obliteration  of  the 
mouth.  There  exist  but  few  instances  of  this  malformation; 
when  it  is  met  with,  it  may  be  remedied  by  making,  with  a  suita- 
ble incision,  an  artificial  buccal  opening,  or  by  separating  the 
adhesions  which  make  it  incomplete. 

Congenital  divisioti  of  the  lips,  or  hare-lip, — The  upper,  and 

*  Essai  d'anat.  path,  sur  les  monstruosites  ou  vices  de  conformation  de  la  face  ; 
these  presentee  et  soutenue  a  la  Faculte  de  Medicine  de  Paris,  le  3  julliet,  1823. 


158  ON   THE    DISEASES   OP    INFANTS. 

very  rarely  the  under  lip,  sometimes  exhibits  solutions  of  con^ 
tinuity  or  vertical  divisions,  either  at  the  middle,  or  at  the  lateral 
part  of  the  raphe,  on  one  or  on  both  sides.  This  congenital  di- 
vision exists  the  more  often  with  hydrocephalia,  anencepalia,  or 
acephalia.  It  may  consist  of  the  commencement  of  the  division, 
of  a  complete  division,  or  of  the  absence  of  a  considerable  portion 
of  the  upper  lip  and  alveolar  arch,  whence  results  a  deformity  of 
the  buccal  opening,  known  vulgarly  by  the  name  of  wolf-mouth. 

Anatomists  have  explained,  in  different  ways,  the  cause  of  this 
malformation. 

One  of  the  most  probable  is  that  given  by  J.  F.  Meckel.  He 
considers  hare-lip  as  the  result  of  an  arrest  of  the  development. 
According  to  him,  the  formation  of  the  upper  lip  commences  at 
three  points,  one  middle  and  two  lateral.  If  these  three  points 
do  not  unite,  but  leave  between  them  the  intervals  which  sepa- 
rated them  in  the  primitive  state  of  embryotic  life,  the  child  then 
has  a  double  hare-lip,  that  is  to  say,  two  vertical  clefts  of  the  up- 
per lip.  Each  of  these  clefts  is  directed  obliquely  outward,  and 
a  red  fleshy  tubercle  exists  between  them,  the  appearance  and 
form  of  which  are  very  variable.  If  but  one  of  these  parts  unites 
whilst  the  other  remains  isolated,  only  one  fissure  or  cleft  exists 
either  on  the  right  or  left  of  the  median  line.  When  the  fissure 
is  double,  the  alae  of  the  nose  are  drawn  outward  to  a  greater  or 
less  extent.  Lastly,  it  very  often  happens,  that  behind  these  so- 
lutions of  continuity  of  the  upper  lip,  the  alveolar  process  is  also 
divided  either  on  one  side  only,  or  on  both  sides  at  once,  and  the 
fissure  is  generally  found  between  the  second  incisor  and  the 
canine  tooth,  although  it  is  possible  to  meet  with  it  between  the 
first  and  second  incisors. 

Division  of  the  palatine  arch  and  velum. — The  two  lateral 
parts  of  the  palatine  arch,  in  place  of  uniting  on  the  median 
line,  as  is  observed  in  the  normal  state,  may  be  arrested  in  their 
development,  and  leave  between  them  a  fissure  varying  in  depth 
and  breadth,  which  establishes  a  communication  between  the 
mouth  and  the  nasal  passages.  And  the  velum  itself  may  like- 
wise have  the  same  imperfection  of  development,  and  exhibit  at 
its  central  part  a  complete  or  incomplete  cleft,  which  interferes 
with  deglutition,  alters  the  tone  of  the  cry,  and  at  a  later  period 
prevents,  to  a  considerable  degree,  or  greatly  impedes  articula 


ON    THE    DISEASES   OP    INFANTS.  159 

tion.  These  divisions  of  the  constituent  parts  of  the  mouth,  may 
exist  separately  or  together  in  the  same  individual.  The  ex- 
treme deformity,  in  times  of  gross  ignorance,  induced  the  belief 
that  it  was  possible  for  a  child  to  be  born  with  the  face  of  a  hare, 
a  calf,  or  wolf — most  absurd  comparisons,  which  are  not  deserv- 
ing mention  at  this  day,  except  to  cite  them  as  examples  of  the 
whimsical  fancy  of  the  human  mind. 

The  curative  means  so  happily  conceived  by  surgeons,  and 
which  have  been  employed  with  so  much  success,  ought  not  to 
be  adopted  in  early  infancy.  It  will  be  necessary  to  wait  until 
the  child  is  more  advanced  in  age,  before  the  operation  for  hare- 
lip, or  that  of  staphyloraphy,  is  performed.  It  remains  for  us  to 
point  out  here  the  particular  care  which  an  infant  affected  with 
this  organic  deviation  requires. 

The  division  of  the  upper  lip  prevents  sucking,  and  especially 
when  it  is  double ;  and  such  is  the  difficulty  in  some  children, 
that  it  is  necessary  to  bring  them  up  with  the  spoon.  The  de- 
glutition of  liquids  in  those  children  affected  with  a  division  of 
the  palatine  arch  and  velum,  is  so  difficult  and  dangerous,  that 
the  child  is  sometimes  threatened  with  suffocation  when  the  li- 
quids taken  pass  into  wrong  passages.  I  cannot  refrain  from  in- 
troducing here  the  excellent  advice  of  professor  Roux  on  this 
subject. 

"  A  child  born  with  a  bifid  velum,  and  at  the  same  time  with 
the  arch  of  the  palate  and  the  lips  perfectly  formed,  can,  without 
difficulty,  take  the  breast  of  its  mother  or  nurse  ;  but  as  it  cannot 
empty  tlie  mouth,  it  sucks  badly,  or  perhaps  cannot  suck  at  all, 
particularly  if  kept  in  a  horizontal  posture ;  deglutition  also  is 
performed  in  a  defective  manner."  M.  Roux  advises  the  placing 
of  the  child  in  a  vertical  position  when  it  is  about  to  suck,  and  to 
assist  the  mechanism  of  suction  by  gently  pressing  the  breast. 
If  there  exist  a  large  communication  between  the  mouth  and  the 
nasal  fossae,  it  will  be  better  to  cause  the  child  to  drink  its  milk 
from  a  small  spoon.  A  child  was  one  day  brought  to  M.  Roux 
affected  with  a  division  of  the  velum  and  arch  of  the  palate,  that 
for  eight  days  had  not  been  able  to  suck.  This  child  was  re- 
duced to  a  state  of  marasmus,  and  appeared  about  to  perish.  M. 
Roux  caused  the  child  to  be  held  erect,  and  in  this  position  gave 
it  a  small  spoonful  of  sugared  water.     In  this  manner  it  drank  a 


160  ON    THE    DISEASES    OP    INFANTS. 

glassful.  From  this  time,  it  was  artificially  fed  by  taking  the 
same  precautionsj  and  was  soon  relieved  from  the  state  of  lan- 
guor and  wasting  in  which  it  had  fallen.* 

The  different  parts  which  constitute  the  buccal  cavity,  may 
likewise  present  some  malformation.  M.  Larochet  has  pointed 
out  as  such — 1st,  The  congenital  fissure  of  the  cheeks,  of  which 
Nicati  has  published  two  cases  ;  in  one,  the  fissure  was  double, 
and  extended  from  the  angle  of  the  lips,  terminating  at  the  globe 
of  the  eye ;  in  the  other,  it  only  existed  on  the  right  side.  This 
last  foetus  presented  besides,  a  division  of  the  left  lip,  and  a  double 
insertion  of  the  umbilical  cord,  one  at  the  umbilicus  and  the 
other  at  the  head.t  These  fissures  probably  depended  on  the 
slow  union  of  the  different  pieces  which  compose  the  bone  of  the 
upper  jaw. 

2dly,  The  uvula  may  be  partially  or  entirely  wanting,  (We- 
del,  Eph.  nat.  cur.  dec.  2,  ohs.  2.) 

3dly,  The  tongue  may  be  very  small,  but  it  is  never  absent 
except  in  the  case  of  absence  of  the  face.  It  may  be  defective  in 
symmetry,  and  not  exhibit  the  sulcus  in  the  centre,  of  which  I 
have  seen  a  very  striking  example.  This  organ  has  been  seen 
deprived  of  all  the  muscles  of  one  side ;  (Cholet,  dans  la  Desser- 
tation  de  Laroche.)  offering  a  bifid  point ;  [Dana  Mem.  de  Tu- 
rin^ 1787.)  The  tongue  may  be  very  small  and  hollowed  like 
a  canal,  (Haller,  Opera  minora^  p.  9.)  As  to  adhesions  of  the 
tongue,  they  have  been  explained  by  saying  that  the  same  state 
is  met  with  in  the  normal  condition  of  the  embryo.  I  have  dis- 
sected with  great  care  three  embryos,  of  six  weeks,  of  two  months, 
and  of  nine  weeks,  and  did  not  find  in  either,  the  tongue  adher- 
ing to  the  subjacent  part.  It  was  very  much  developed,  and  had 
no  other  adhesions  except  at  the  base  and  frosnum.  The  lateral 
and  inferior  parts  were  free. 

The  froenum  of  the  tongue  may  be  too  long,  and  thus  may 
embarrass  the  movements  of  this  organ  and  the  mechanism  of 
sucking.  The  froenum  should  be  cut  immediately  after  birth  ; 
this  may  be  done  by  raising  the  tongue  with  a  grooved  director 

*  Memoire  sur  la  staphyloraphie,  ou  Suture  du  voile  du  palais.     Paris,  1826. 
t  Loc.  cit. 

t  Were  there  not  rather  two  umbilical  cords,  and  was  not  this  a  trace  of  the  inclu- 
sion of  another  fcEtus  1 


ON   THE    DISEASES   OF    INFANTS.  161 

held  in  the  left  hand,  whilst  with  a  scissors  in  the  right  hand,  the 
preternatural  membrane  which  forms  the  adhesion,  is  cut  to  the 
required  extent.  If  the  cutting  of  the  vessels  causes  a  hemor- 
rhage, which  is  increased  by  the  suction  of  the  child,  it  will  be  ne- 
cessary to  cauterize  the  veins  and  arteries  with  nitrate  of  silver, 
or  with  a  red  hot  needle.* 

The  Vandermonde  journal  of  medicine  and  pharmacy  contains 
an  example  of  a  child  born  with  a  monstrous  tongue.  After  the 
birth  of  this  child,  this  organ  appeared  much  longer  and  thicker 
than  usual,  and  entirely  prevented  sucking.  The  surgeon  in  at- 
tendance having  examined  it,  found  that  it  adhered  to  the  gums 
and  lower  jaw  by  a  spongy  tumor  of  the  size  of  a  small  filbert. 
He  tried  by  all  the  means  in  his  power  to  separate  the  tumor 
from  the  tongue,  but  the  hemorrhage,  which  was  considerable, 
intimidated  him.  The  part  which  he  had  begun  to  separate  af- 
terwards united,  the  tumor  increased  in  size  from  day  to  day, 
and  affected  the  tongue,  with  which  it  appeared  to  unite  itself ; 
and  after  a  short  time  no  difference  could  be  perceived  between 
the  tumor  and  the  tongue.  "During  this  interval  the  child 
lived  only  on  liquid  aliments,  which  were  introduced  far  into  the 
mouth  to  enable  it  to  swallow,  which  it  accomplished  by  draw- 
ing the  lower  jaw  farther  back  than  the  upper.  In  this  mannei 
it  took  the  breast ;  and  it  was  quite  a  pleasure  to  observe  with 
what  quickness  and  dexterity  this  young  infant,  instructed  by  its 
wants,  advanced  and  drew  back  the  lower  jaw  in  drawing  at  the 
breast."  In  proportion  as  the  child  increased  in  age  the  tongue 
increased  in  size  ;  at  last  it  was  two  inches  thick,  and  projected 
four  fingers  breadth  from  the  mouth.  The  incisors  and  canine 
teeth  fell  out ;  the  lower  jaw  was  bent  in  the  middle,  and  pre- 
sented a  hollow  in  which  the  tongue  was  lodged.  The  child 
could  chew  and  articulate  sounds  in  spite  of  this  infirmity .f 

*  The  work  of  J.  L.  Petit,  entitled  Observations  anatomiques  et  pathologiques,  on 
the  froenum  of  the  tongue,  may  be  advantageously  consulted.  In  a  chapter  in  his  Traite 
des  vial,  chir.,  will  be  found  some  important  observations  which  deserve  the  attention 
of  the  practitioner.  The  simple  incision  of  the  froBnum  is  not  an  operation  to  be 
done  lightly  ;  and  although  at  this  day  it  is  not  considered  so  dangerous  as  it  was  for- 
merly, yet  care  should  be  taken  to  prevent  and  to  remedy  accidents  which  may  at- 
tend it. 

t  Observations  published  by  M.  Mauraut,  surgeon  in  Mortigue  in  Provence, 
Journ.  de  med.,  chir.  et  pharm.  1. 15,  p.  158. 

31 


162  ON   THE   DISEASES    OF    INFANTS. 

This  child  ought  to  have  been  reheved  by  perforating  the 
tongue  and  passing  a  double  ligature,  which,  being  tightened 
gradually  on  each  side,  would  have  detached,  by  degrees,  the 
superfluous  appendage  without  hemorrhage.  It  is  known  that 
Mirault  of  Angers  has  performed  this  operation  with  success  on 
an  adult. 

4thly,  The  lower  jaw  may  be  wanting,  or  be  of  a  remarkably 
small  size.  I  have  seen  a  child  born  with  all  the  constituent 
parts  of  the  mouth  reduced  to  extremely  small  dimensions.  I 
shall  here  record  this  curious  case  in  detail. 


CASE  IX.- — On  the  25th  of  June,  1826,  a  young  female  infant  was 
brought  to  the  Hospice  des  Enfans  Trouves.  The  inferior  portion 
of  the  face  was  very  much  narrowed  ;  and  the  two  cheeks,  instead 
of  being  round  and  projecting,  were  almost  concave  ;  the  opening  of 
the  mouth  was  very  narrow,  the  lips  round  and  prominent,  the  low- 
er jaw  projecting-  and  extremely  narrow;  the  tongue  straight  and 
pointed,  having  altogether  the  form  of  a  hare's  tongue  ;  the  isthmus 
of  the  fauces  was  very  narrow.  The  child  could  not  take  the  breast, 
and  drank  with  great  difficulty;  the  imperfect  deglutition  caused 
sometimes  a  dangerous  suffocation.  The  cry  was  acute  and  jerking, 
and  both  the  parts  constituting  it  were  distinctly  heard.  This  child 
soon  perished  from  enteritis,  on  which  account  it  was  placed  in  the 
infirmary.  On  the  examination  of  the  dead  body,  the  various  parts 
just  enumerated  were  measured,  and  were  of  the  following  dimen- 
sions :  the  anterior  orifice  of  the  mouth  was  six  lines  in  diameter  ; 
the  tongue,  from  the  base  to  the  point,  two  inches  and  two  lines,  and 
its  diameter  near  the  base,  six  lines,  and  at  the  point,  five  ;  the  dis- 
tance between  the  two  large  cornua  of  the  os  hyoides,  was  seven 
lines  ;  and  the  distance  between  angles  of  the  lower  jaw  was  found 
to  be  fifteen  lines  ;  the  greatest  diameter  of  the  palatine  arch  was 
fourteen  lines;  the  ossification  of  the  lower  jaw  was  as  much  ad- 
vanced as  it  usually  is  at  birth,  and  the  tongue  possessed  all  its 
muscles. 

Thus,  all  these  parts  were  of  their  natural  length,  but  not  of 
their  ordinary  breadth,  so  that  it  may  be  said  that  the  lateral  por- 
tions of  the  face  had  been  compressed  in  a  manner  to  hinder  their 
development  in  breadth.     I   acknowledge  that  I  could  not  find 


ON   THE    DISEASES   OP    INFANTS.  163 

the  cause  of  the  deformity  in  this  child,  who,  in  other  respects, 
possessed  a  perfect  organization. 

§  II.  Passive  congestion. — :Passive  congestions  of  the 
buccal  membrane  are  rare  during  intra-uteritie  life  ;  yet  I  once 
saw  in  an  infant  just  born  an  ecchymosis  at  the  base  of  the 
tongue  ;  it  was  of  a  violet  color,  and  spread  from  the  base  to  the 
middle  part  of  the  organ ;  it  penetrated  to  the  depth  of  three 
lines.  The  tissue  of  the  tongue  wasvery  much  softened  at  this 
place.  There  was  nothing  else  in  the  general  condition  of  this 
subject  worthy  of  remark. 

It  is  very  common  to  meet,  at  birth,  with  instances  in  which  the 
buccal  membrane  is  the  seat  of  a  well-marked  congestion.  This 
congestion,  and  the  redness  arising  from  it,  disappear  by  degrees 
after  birth;  but  certain  portions  may  remain,  for  some  weeks, 
the  seat  of  red  patches,  which  however  are  gradually  effaced. 
An  ecchymosis  of  greater  or  less  extent,  is  often  seen  continuing 
for  a  long  time  in  the  palatine  arch. 

§  III.  Inflammations. — Inflammations  of  the  buccal  mem- 
brane are  distinguished  by  the  term  stomatitis. 


stomatitis. 

It  is  impossible  to  convey,  by  a  general  description,  a  pro- 
per knowledge  of  stomatitis,  because  every  part  which  enters 
into  the  composition  of  the  parietes  of  the  mouth,  may  be- 
come the  special  seat  of  the  varieties  of  inflammation  which  are 
developed  in  this  cavity.  The  disease  then  takes  a  peculiar  as- 
pect, and  gives  rise  to  symptoms  which  are  proper  to  it ;  so  true 
it  is,  that  the  different  modes  of  alteration  of  organs  are  often  the 
principal  and  essential  cause  of  the  difference  of  the  symptoms  of 
diseases. 

I  shall  therefore  describe  stomatitis  under  the  following  va- 
rieties: 

Erythematic, 

With  altered  secretion,  (muguet,) 

Follicular,  (aphtha3,) 

Ulcerous, 

Gangrenous. 


164  ON    THE    DISEASES    OF    INFANTS. 


ERYTHEMATIC   STOMATITIS. 

The  congested  state  in  which  the  buccal  membrane  always 
exists  in  new-born  children,  disposes  it  to  become  the  seat  of 
erythematic  stomatitis,  an  affection  usually  characterized  by  red- 
ness, heat,  and  sometimes  by  dryness  of  the  parietes  of  the  mouth 
and  of  the  tongue.  This  is  usually  the  first  degree  or  precursory 
symptom  of  the  other  varieties  of  stomatitis.  It  varies  in  inten- 
sity, and  is  either  transitory  in  its  duration,  or  may  continue  for 
a  length  of  time.  It  often  accompanies  inflammation  of  the  sto- 
mach or  intestinal  canal ;  but  it  rarely  gives  rise  to  any  febrile 
derangement  in  very  young  infants  ;  but  in  children  from  seven 
to  nine  months  of  age,  it  is  often  accompanied  by  this  symptom. 
The  inflammation  is  confined,  in  some  cases,  to  one  part  of  the 
mouth,  while  in  others  it  occupies  the  entire  cavit^r,  and  spread- 
ing to  the  lips,  they  tumefy,  excoriate,  crack,  and  frequently  be- 
come the  seat  of  herpes  lahialis. 

When  this  inflammation  is  of  long  duration,  it  may  produce 
an  abundant  ptyalism,  particularly  in  children  from  seven  to 
nine  months. 

Simple  erythematic  stomatitis  promptly  yields  to  emollient 
gargles  and  to  milk  diet ;  and  when  it  is  accompanied  by  a 
phlegmasia  of  the  stomach  or  intestines,  it  disappears  in  propor- 
tion to  the  dissipation  of  the  gastric  inflammation  accompany- 
ing it. 

STOMATITIS    WITH    ALTERED    SECRETION,    OR     MUGUET. 

Many  pathologists  have  confounded  muguet  with  aphthae.  In 
order  to  avoid  the  confusion  into  which  they  have  fallen,  we  will, 
in  the  first  place,  establish  the  characteristic  differences  of  these 
two  diseases.  It  was  not  until  the  labors  of  MM.  Breschet  and 
Guersent  appeared,  that  sufficient  data  were  established  in  rela- 
tion to  this  variety  of  inffammation.  M.  Veron,  in  an  essay  read 
at  the  Academic  royale  de  Medicine,  and  M.  Lelut,  in  a  paper 
placed  in  Archives  general  de  medicine,  (March,  1827,)  have 
contributed  much  to  elucidate  the  history  of  the  disease  in  ques- 
tion. We  will  endeavor  to  present  its  history  divested  of  all  dis- 
cussion, and  the  vain  show  of  scholastic  erudition. 

It  is  characterized  by  a  concretion  of  mucus  on  the  surface  of 


ON  THE    DISEASES    OF    INFANTS.  165 

inflamed  mucous  membranes,  whether  the  membrane  be  an  epi- 
thelium or  not. 

This  concretion  may  be  observed  in  the  mouth,  oesophagus, 
stomach,  and  small  or  large  intestines.  This  last  assertion  may- 
appear  strange  after  what  some  physicians,  and  particularly  M. 
Veron,  have  said  on  this  subject ;  but  I  advance  it  here,  as  it  will 
presently  be  supported  by  unexceptionable  proofs.  I  will  con- 
fine myself  to  muguet  of  the  mouth. 

This  affection  appears  under  three  different  forms — 1st,  under 
the  form  of  very  small  white  points,  dispersed  upon  the  tongue 
and  parietes  of  the  mouth  ;  2dly,  that  of  variously  sized  shreds  ; 
3dly,  that  of  a  membrane  entirely  covering  the  tongue,  or  spread 
over  the  other  parts  of  the  buccal  cavity.  I  do  not  speak  of  the  yel- 
low or  red  color  which  the  pellicle  sometimes  assumes,  because 
it  depends  on  the  contact  of  bile,  or  on  a  sanguineous  exhalation 
on  the  surface  of  the  mucous  membrane,  circumstances  altogether 
independent  of  the  disease  now  under  consideration. 

This  excretion,  under  what  form  soever  it  may  appear,  is 
usually  preceded  by  an  erythematic  inflammation  of  the  surface 
of  the  tongue,  or  of  the  parietes  of  the  mouth.  When  inflamma- 
tion has  continued  one,  two,  or  three  days,  there  are  seen  at  the 
extremity,  or  on  the  sides  of  the  tongue,  or  on  the  internal  sur- 
face of  the  lip,  small  white  points  which  appear  to  crown  the  pa- 
pillae of  the  membrane  to  which  they  adhere.  I  have  examined 
the  seat  of  this  excretion  with  great  care,  and  I  never  saw  it  un- 
der the  epithelium,  on  the  surface  of  which  it  is  always  seated. 
It  overspreads  the  membrane  like  mucus,  of  which  indeed  the 
muguet  is  but  a  morbid  concretion. 

This  is  the  first  degree  of  the  disease,  which,  as  I  have  just  re- 
marked, is  always  preceded  by  inflammation  of  the  mouth.  If 
the  inflammation  makes  no  progress,  and  if  the  excretion  accom- 
panying it  is  suspended,  the  white  points  alluded  to  soon  disap- 
pear, and  the  disease  may  be  regarded  as  mild. 

When  the  inflammation  has  made  some  progress,  the  white 
points  unite  and  form  small  laminae  either  on  the  surface  of  the 
tongue  or  on  the  internal  surface  of  the  lips  and  cheeks.  These 
laminae,  becoming  very  thick,  exfoliate  and  detach  themselves, 
leaving  in  their  places  an  inflamed  surface,  which  soon  secretes 
materials  for  a  new  concretion,  until  at  last,  the  inflammation 


166  ON    THE    DISEASES    OF    INFANTS. 

ceasing,  the  reproduction  of  morbid  matter  is  no  longer  to  be  ob- 
served. 

The  disease  increasing,  the  inflammation  spreads  rapidly  and 
deeply  over  the  whole  cavity  of  the  mouth ;  the  laminae  of  which  I 
have  spoken,  quickly  uniting,  form  a  pellicle  of  a  greater  or  less 
extent  and  thickness,  which  spreads  over  the  tongue,  sides  of  the 
mouth,  and  velum.  Under  these  circumstances,  as  in  the  pre- 
ceding, the  disease  is  said  to  be  confluent  or  malignant.  Such  is 
the  exhibition  of  the  three  principal  aspects  of  this  inflanmiation 
as  it  appears  in  the  mouth.  These  varieties  are  more  remarka- 
ble with  reference  to  their  ordinary  seat.  The  pointed  variety 
usually  occupies  the  extremity  and  edges  of  the  tongue  ;  that  in 
laminse  appears  on  the  internal  surface  of  the  lips  and  cheeks ; 
the  membraniform  occurs  at  the  base  of  the  tongue  and  on  the 
velum.  To  a  certain  extent,  the  reason  of  this  diflerence  of  ap- 
pearance can  be  explained.  The  pointed  variety,  which  is  no- 
ticed on  the  upper  part  of  the  tongue,  occurs  in  the  numerous 
papillae,  secreting  at  their  extremities  small  mucous  drops  which 
immediately  concrete.  As  the  papillae  and  villosities  of  the  mu- 
cous membrane  are  longer  and  less  fine  at  the  palate,  base  of  the 
tongue,  and  on  the  internal  surface  of  the  cheeks,  the  mucus  is 
secreted  in  the  form  of  a  covering,  and  concretes  in  the  same 
manner,  assuming  the  membraniform  appearance  spoken  of 
above. 

We  shall  now  take  several  interesting  questions  into  considera- 
tion, and  endeavor  to  ascertain  the  nature,  causes,  symptoms, 
complications,  and  treatment  of  this  species  of  inflammation. 

It  is  admitted  as  a  fact,  sanctioned  by  the  observations  of  the 
present  time,  that  the  accumulation  of  blood,  redness,  and  with- 
out doubt,  pain  in  the  mucous  membrane  of  the  mouth,  always 
precede  the  appearance  of  the  white  points.  It  is  also  worthy  of 
remark,  that  the  pellicular  or  curdy  production  takes  the  place 
of  the  mucus  which  moistens  and  lubricates  the  mouth.  Thus, 
then,  this  affection  follows  an  accumulation  of  blood  in  the  in- 
flamed membrane,- and  replaces  the  normal  secretion  of  mucus. 
It  is  probable  that  the  blood  accumulated  by  the  inflammatory 
stimulus  in  the  thickness  of  the  mucous  tissue,  transmits  to  it  the 
materials  of  secretion,  the  product  of  which  concretes  on  the  sur- 
face of  the  epithelium,  in  proportion  as  it  is  deposited  there. 


ON    THE    DISEASES   OF    INFANTS.  167 

Does  this  facility  in  the  mucus  to  concrete  arise  from  the  blood, 
in  children  and  sometimes  in  adults  who  are  found  in  analo- 
gous cases,  having  been  rendered  more  plastic  and  rich  in  fibrin 
by  the  inflammatory  condition,  thereby  supplying  the  elements 
of  a  mucus  abounding  in  fibrin  ?  This  is  a  question  the  solu- 
tion of  which  we  will  leave  to  those  who,  more  fortunate  than 
we,  have  better  authority  than  conjecture.  The  researches  of  M. 
Lelut  go  to  the  support  of  this  opinion;  for  this  physician,  hav- 
ing treated  the  pellicle  or  false  membrane  by  chymical  agents, 
arrived  at  results  nearly  resembling  those  which  have  been  ob- 
tained from  the  examination  of  mucus  by  Fourcroy,  Schwilgue, 
Yauquelin,  Berzelius,  and  Hatchett ;  or  of  the  epidermis  by  Bi- 
chat,  Vauquelin,  and  Hatchett;  or  of  the  buff  of  the  blood,  the 
false  membrane  of  the  serous  membranes,  of  the  bladder,  or 
croup  by  Schwilgue,  Double,  Guersent,  Desrouelles,*  and  Bre- 
tonneau.t  Such,  are  the  few  data  we  possess  on  the  nature  of 
the  disease ;  let  us  now  examine  the  causes. 

This  affection  shows  itself  more  commonly  in  early  infancy. 
Sucking  infants  are  more  often  the  subjects  of  it  than  those  more 
advanced  in  age.  There  exists  something  peculiar  in  the  consti- 
tution of  one  so  young  which  singularly  disposes  it  to  this  modi- 
fication of  inflammation ;  and  those  children  that  are  crowded 
together  in  the  same  place,  are  feeble  and  wretched,  and  that  re- 
ceive unsuitable  nourishment  at  an  age  when  nutrition  plays  the 
principal  part  in  the  functions  of  the  economy,  are  the  subjects  of 
stomatitis  and  muguet  of  the  greatest  intensity.  There  is  no 
part  of  the  year  that  can  be  mentioned  as  peculiarly  favorable  to 
the  development  of  this  disease.  It  prevails  with  almost  equal 
intensity,  and  at  all  times,  at  the  Hospice  deg  Enfans  Trouves, 
In  the  quarter  ending  in  March,  1826,  in  two  hundred  and  nine- 
ty patients,  there  were  thirty-four  cases  of  it.  In  the  quarter  end- 
ing in  June,  in  two  hundred  and  thirty -five  patients,  there  were 
thirty-five  ;  in  the  quarter  ending  in  September,  in  two  hundred 
and  thirteen  sick,  there  were  one  hundred  and  one  cases ;  and 
forty-eight  cases  in  the  quarter  ending  in  December,  among  one 
hundred  and  eighty-nine  patients.  M.  Baron  has  seen  it  prevail 
among  a  number  of  individuals  at  certain  periods,  without  being 

*  Traite  theorique  et  pratique  du  croup.   Paris,  1824. 
t  Archives  generates  de  medicine,  March,  1827. 


168  ON   THE    DISEASES    OF    INFANTS. 

able  to  assign  for  its  cause  any  influence  from  temperature.  I 
am  disposed  to  think  that  the  development  of  this  disease  is  more 
connected  with  the  constitution  of  the  patients,  and  to  their  dispo- 
sition to  inflammation  of  the  mucous  membranes,  than  to  any 
cause  of  an  atmospheric  nature. 

I  do  not  believe  it  is  contagious.  M.  Baron  rejects  entirely  the 
idea  of  contagion,  from  often  having  seen  children  drink  from 
the  cup  used  by  those  who  have  been  affected,  without  contract- 
ing the  disease.     This  fact  I  also  have  observed. 

From  these  considerations,  it  follows  that  the  causes  of  this 
disease  are  :  the  first  period  of  infancy — bad  nutrition — the  as- 
semblage of  a  great  number  of  children  in  the  same  place — de- 
bility— inflammation  of  the  buccal  membrane — and  lastly,  the 
disposition  which  the  mucous  membranes  exhibit  in  young  chil- 
dren to  be  covered,  when  they  are  inflamed,  with  thick,  curdy, 
and  membraniform  concretions. 

The  local  symptofns  are  found  traced  in  the  description  given 
of  the  development  and  form  of  the  morbid  excretion,  which 
shows  itself  on  the  surface  of  the  inflamed  mouth.  As  to  gene- 
ral symptoms,  they  scarcely  exist  in  very  young  infants  ;  fever 
is  hardly  ever  manifested.  I  counted  the  pulse  and  the  beatings 
of  the  heart  in  forty  children,  aged  from  one  to  twenty  days,  af- 
fected with  it,  and  found  fifty,  sixty,  sixty-five,  eighty,  and  in  one 
instance  one  hundred,  pulsations  in  a  minute.  With  the  excep- 
tion of  the  last  case,  the  number  of  pulsations  did  not  differ  from 
the  natural  state  of  the  pulse,  as  will  be  seen  on  comparing  what 
has  been  just  stated  with  what  has  been  already  said  upon  the 
state  of  the  pulse. 

The  skin  is  usually  hot  and  dry,  and  the  thirst  great.  The 
cry  does  not  vary  except  with  reference  to  its  strength  and  fee- 
bleness ;  yet  when  the  membraniform  concretions  spread  to  the 
glands,  and  cover  the  pillars  of  the  velum,  the  cry  then  becomes 
husky. 

It  is  sometimes  complicated  with  other  phlegmasise.  In  fifty 
cases  which  were  fatal  either  from  the  progress  of  the  disease,  or 
from  some  other  affections,  I  found,  as  complications,  a  phlegma- 
sia of  the  cerebro-spinal  apparatus  in  two  children ;  of  the  skin 
in  four ;  of  the  respiratory  and  circulatory  apparatus  in  twelve ; 
and  of  the  digestive  apparatus  in  thirty-two.     Whence  it  results 


ON   THE    DISEASES   OP    INFANTS.  169 

that  the  inflammation  of  the  digestive  apparatus  is  its  most  usual 
accompaniment,  while  the  other  phlegmasiae  are  of  accidental 
occurrence. 

In  the  thirty-two  children  presenting  the  complication  of  phleg- 
masiae of  the  ahmentary  canal,  there  were  ten  where  the  sto- 
mach was  not  inflamed.  In  six  of  these,  the  large  intestines, 
and  in  four  the  small  intestines,  were  found  more  or  less  in- 
flamed. As  to  the  remaining  twenty-two,  they  showed  an  inflam- 
mation of  the  stomach,  ossophagus,  or  of  some  part  of  the  great 
or  small  intestines. 

This  disease,  therefore,  is  not  always  a  sign  of  gastritis,  since 
it  can  exist  without  this  phlegmasia;  but  it  coexists  almost  always 
with  an  inflammatory  state  of  some  part  of  the  intestinal  canal. 
This  assertion,  already  made  by  several  authors,  needed  still  the 
support  of  well-established  facts,  and  these  are  what  I  had  pro- 
posed to  give  here. 

The  treatment  of  muguet  flows  naturally  from  the  exposition 
of  the  facts  which  have  been  exhibited,  and  from  the  nature  of 
the  considerations  to  which  they  give  rise. 

When  it  is  simple,  and  consists  of  nothing  more  than  a  few* 
points  disseminated  over  the  surface  of  the  tongue,  or  on  the  bor- 
ders of  the  lips,  all  that  is  required  is  to  wash  the  mouth  of  the 
child  several  times  a  day  with  a  piece  of  lint  soaked  in  a  decoc- 
tion of  marshmallows.  If  it  should  be  more  confluent,  and  compli- 
cated with  a  phlegmasia  of  the  digestive  organs,  or  of  some  other 
important  part,  in  addition  to  emollient  gargles,  the  accompany- 
ing disease  ought  to  be  met  by  appropriate  treatment ;  which 
will  be  found  in  the  history  of  each  of  these  diseases.  I 
have  seen  this  treatment,  simple  as  it  appears,  completely  suc- 
cessful in  the  hands  of  M.  Baron.  M.  Guersent  advises,  besides, 
the  employment  of  some  mucilaginous  decoction  to  which  is 
added  a  fourth  part  of  the  chloride  of  soda,  as  a  wash  for  the 
mouth  of  the  child.  This  preparation,  diluted  with  muci- 
lage, observes  M.  Guersent,  appears  to  me  preferable  to  a  solu- 
tion of  subborate  of  soda,  or  that  of  the  sulphate  of  zinc.  It 
is  equally  preferable,  in  injections,  to  lime  water,  which  is  irrita- 
ting to  the  intestines.*    A  small  quantity  of  akim  may  be  added  to 

*  Guersent,  art.  Muguet,  du  Diet,  de  Med.  in  21  vols. 

22 


170  ON   THE    DISEASES    OF    INFANTS. 

the  gargles,  after  having   ineifectually  employed  emollient  lo- 
tions. 

The  remarks  which  have  been  made  on  confluent  muguet, 
are  equally  applicable  to  certain  phlegmasiae  of  the  mouth 
and  gums,  which  produce  a  concretion  more  or  less  abundant, 
covering  with  white  or  yellow  pellicles  the  gums  and  interna,! 
surface  of  the  cheeks.  Several  authors  have  described  this 
phlegmasia  under  the  name  of  aphthas ;  others  have  called  it 
pustular,  pellicular  inflammation,  etc.  These  varieties  may  be 
referred  to  stomatitis  with  altered  secretions,  and  should  be  treat- 
ed with  the  same  therapeutic  means. 

FOLLICULAR    STOMATITIS,  OR    APHTHiE. 

For  a  long  time  pathologists  were  not  agreed  as  to  the  true 
nature  and  seat  of  aphthae  ;  in  order  to  be  satisfied  of  this,  it  is 
only  necessary  to  cast  a  glance  over  the  principal  works  which 
have  been  published  on  this  subject. 

Hippocrates  and  Aretasus,  it  is  said,  described  this  disease,  but  it 
is  difficult  to  find  the  essential  characters  of  it  mentioned  in  their 
writings.  Hippocrates  mentions  it  without  .  any  description 
"//z  cctatihus  autem  talia  eveniunt.  Parvis  quidem,  et  recens 
natis  pueris  aphthce  vomitns,  tusses,  vigilice,  pavores,  umbilici 
inflaTnmationes,  aurium  humiditates.^''*  Aretaeus  scarcely  enables 
us  to  undersand,  in  the  following  passage,  whether  he  is  speaking 
of  aphthae.  "  Cmstam  vero  circumveniunt  rubor  excellens  et  in- 
Jla'm7natio  et  venarum  dolor ^  qiiemadmodum  in  carbuncido  ;  ex- 
iguce  rarceque  jJustulcB  quasGrcBci  exanthemata  vocant,  orientes, 
hisque  alice  supervenientes  in  itsum  coalescunt ;  atque  inde  la- 
tum ulcus  efficetur.^^t  If  Aretaeus  wished  to  designate  by  the  ex- 
pression exigucB  rarcequcB  pustidoi,  the  inflamed  follicles  of  the 
mouth,  it  must  be  allowed  that  he  has  lost  the  proper  distinction 
of  it  in  the  confused  description  of  the  various  affections  of  the 
mouth,  each  of  which  merits  a  place  in  a  perfect  and  complete 
nosological  arrangement. 

The  commentators  of  Hippocrates,  Galen,  Celsus,  and  Are- 
taeus have  exhausted  themselves  in  vain  conjectures  to  ascertain  to 

♦  Aphorism  24,  Sec,  3. 

t  De  tonsillarum  ulceribus,  cap.  9. 


ON    THE    DISEASES    OF    INFANTS.  171 

what  alterations  of  tissue  aphthse  are  to  be  referred.  Some  phy- 
sicians, such  as  Boerhaave,  Van  Swieten^  Stohl,  Armstrong,  and 
Underwood,  have  appUed  this  term  to  ulcers  of  the  mouth,  what- 
ever may  have  been  their  primitive  form.  Others,  as  Sylvius, 
Mercurialis,  Etmaller,  and  Pinel.  have  regarded  them  as  vesi- 
cular pustules,  white  in  the  centre,  red  at  their  borders,  having  a 
great  analogy  to  the  mucous  disease  of  RoBderer  and  Wagler ;  an 
dpiniori  to  which  Gardien  appears  to  incline.  Which  of  these 
various  opinions  shall  be  adopted  ? 

Bichat,  whose  genius  has  discovered  all  the  advantages  that 
may  be  drawn  from  the  study  of  the  anatomical  characters  of 
diseases,  in  order  to  establish  positively  their  differences  and  ana- 
logies, says,  on  finishing  his  chapter  on  the  mucous  chorion  : 
"  Are  aphthas  an  affection  of  the  mucous  chorion  ?  do  they  apper- 
tain to  the  papillae  7  are  they  seated  in  the  glands  ?  do  they  arise 
from  the  isolated  inflammation  of  these  glands,  while  catarrh  is 
characterized  by  a  general  inflammation  of  the  mucous  system 
spread  to  a  great  extent  ?  All  these  questions  deserve  to  be  exa- 
mined, and  Pinel  has  felt  the  defects  of  pathological  anatomy  on 
this  point."* 

Gardien  has  not  been  willing  to  attempt  the  solution  of  a 
question,  upon  which,  says  he,  Bichat  has  not  ventured  to  pro- 
nounce an  opinion.  He  has  been  contented  to  describe  in  detail, 
and  with  great  care,  the  history  of  the  opinions  advanced  upon 
the  nature  and  progress  of  aphthae  from  the  remotest  antiquity  to 
the  present  day.f  But  whatever  distrust  one  may  have,  as  regards 
his  own  abilities,  ought  he  always  on  that  account  to  stop  at 
difficulties  which  have  foiled  men  of  greater  talents  ?  and  from 
the  constant  progress  which  is  made  in  pathological  anatomy, 
furnishing  incessantly  new  materials,  are  we  not  at  this  day  bet- 
ter able  to  solve  the  problems  which  in  the  time  of  Bichat  were 
considered  as  not  admitting  of  solution  ?  I  am  of  this  opinion  ; 
and  though  I  might  perhaps  do  better  by  imitating  a  modesty 
so  honorable  to  him,  it  would  be  prejudicial  to  the  cause  of  sci- 
ence, since  it  confines  our  efforts  and  arrests  our  discoveries.  I 
will  therefore  attempt  to  respond  to  the  questions  of  Bichat,  and 

*  Anat  Gen.  Tome  4,  p.  437. 

t  Gardien,  Traite  complet  d'accouc^imens  et  des  Maladies  desfemmes  tides  enfans, 
Tom.  4,  p.  115. 


172  ON   THE    DISEASES    OF    INFANTS. 

show  that  aphthae  consist  of  an  inflammation  of  the  muciparous 
follicles  of  the  mouth. 

The  muciparous  follicles  of  the  mucous  membrane  of  the  mouth 
are  invisible  in  their  ordinary  state,  and  remain  hidden  in  the 
thickness  of  the  membrane,  and  compensate  by  their  infinite 
number  for  the  smallness  of  their  size  ;  but  when  they  begin  to 
inflame  and  to  tumefy,  they  appear  on  the  internal  surface  of  the 
lips  and  cheeks,  on  the  pillars  of  the  velum  and  the  palatine  arch, 
on  the  inferior  surface  and  the  lateral  parts  of  the  base  of  the 
tongue,  under  the  form  of  small  white  points,  sometimes  exhibit- 
ing a  colored  spot  in  their  centre,  slightly  prominent,  and  often 
surrounded  by  a  slight  inflammatory  circle.  These  follicles  are 
either  isolated  and  few  in  number,  or  multiplied  and  spread  over 
every  part  of  the  mouth.  Sometimes  they  may  be  felt  with  the 
finger,  when  they  are  not  sufficiently  distinct  to  be  seen.  They 
often  do  not  stop  at  the  mouth,  but  spread  to  the  cesophagus, 
stomach,  and  intestinal  tube.  I  shall  confine  myself  here  to  the 
consideration  of  the  follicles  of  the  mouth. 

The  inflammation  of  these  follicles  is  sometimes  arrested  in  the 
first  stage,  and  will  remain  for  a  greater  or  less  time  without  pro- 
ducing any  symptom,  but  this  inflammation  will  often  make  a 
considerable  progress,  and  insensibly  produces  the  following 
alterations : 

The  follicular  points  enlarge,  preserving  also  their  circular, 
primitive  form ;  and  from  their  central  aperture  there  soon  issues 
a  white  matter,  which  being  squeezed  by  the  epithelium,  the  ulcer- 
ation of  which  soon  commences,  leaves  the  white  puriform 
matter  of  which  1  have  just  spoken,  freely  exuded  over  the  parts. 
The  aphthoe  take  a  new  aspect,  and  then  commences  the  second 
stage,  or  period  of  ulceration.  The  projecting  points  of  which 
mention  has  been  made,  are  neither  tubercles,  as  M.  Gardien  has 
said,  nor  vesicles  nor  pustules  as  has  been  asserted  by  others ; 
but  they  are  evidently  the  muciparous  follicles,  as  their  central 
orifice  and  unvarying  form  demonstrate.  They  are  analogous, 
in  every  respect,  to  those  which  are  found  in  the  stomach, 
small  intestines,  caecum,  and  colon.  Now,  if  this  be  the  case, 
why  then  does  there  exist  a  doubt,  that  the  ulceration  which 
follows  at  these  follicular  points,  is  the  result  of  their  inflamma- 
tion? wherefore  is  there  still  an  opposition  to  the  idea  that  aphthse 


ON  THE  DISEASES   OP    INFANTS.  173 

are  inflamed  follicles  of  the  buccal  cavity,  when  there  is  no  doubt, 
at  the  present  day,  that  the  round  ulcers  throughout  the  small  in- 
testines are  the  effects  of  an  inflammation  of  the  glands  in  those 
regions,  and  which  possess  the  greatest  analogy  to  those  of  the 
mouth  ?  But  the  better  to  elucidate  a  question  upon  which 
Bichat  has  hesitated  to  give  an  opinion,  let  us  pursue  our 
description. 

The  follicle  once  broken,  consists  only  of  a  prominent  mark ; 
it  is  a  superficial  ulcer,  with  circular  borders,  sometimes  slightly 
cupped,  more  or  less  tumefied,  and  almost  always  surrounded  by 
a  red  inflammatory  circle.  That  the  borders  and  the  centre  of  this 
light  ulceration  often  secrete  a  white,  pultaceous  matter,  adhe- 
ring like  a  small  scab,  ending  by  becoming  detached  and  ejected 
with  the  saliva  of  the  child. 

Isolated  aphthas  generally  occupy  the  internal  surface  of  the 
lower  lip,  the  froenum  of  the  tongue,  the  internal  surface  of  the 
cheeks,  and  when  there  are  no  teeth,  the  summit  of  the  gums. 

If  the  aphthae  are  in  great  numbers  and  very  near  each  other, 
their  borders  unite,  the  curdy  matter,  which  they  excrete,  spreads 
from  one  to  the  other,  forming  a  bed  of  greater  or  less  extent  and 
thickness.  It  is  then  that  aphthae  are  confounded  with  muguet, 
but  they  may  always  be  distinguished,  in  considering  the  deve- 
lopment of  the  inflamed  follicles,  and  the  solution  of  continu- 
ity which  does  not  exist  in  the  latter  disease  ;  besides,  the  excre- 
tion which  accompanies  aphthae  always  follows  the  ulceration, 
and  almost  always  exists  at  the  internal  part  of  the  lips  and 
cheeks,  while  the  white  points  of  the  other  affection  appear  at 
first  on  the  lateral  parts,  and  towards  the  extremity  of  the  in- 
flamed tongue,  extending  afterwards  to  the  surrounding  parts. 

Aphthae  do  not  always  present  the  same  characters  in  the  vari- 
ous places  of  their  development ;  sometimes  when  the  follicular 
points  are  about  to  ulcerate,  the  edges  of  the  ulcers,  instead  of 
being  covered  with  a  slight  curdy  excretion,  exhale  a  small 
quantity  of  blood,  which  concretes  under  the  form  of  a  slight 
brown  scab,  mistaken  by  some  authors,  as  in  malignant  sore 
throat,  for  a  gangrenous  eschar.  Bat  Guersent  and  Bretonneau 
have  clearly  demonstrated  that  what  has  been  taken  for  gangre- 
nous affections  of  the  throat  is  really  nothing  but  an  inflammation 
of  the  mucous  tissue  without  loss  of  substance,  an  inflammation 


174  ON   THE    DISEASES    OP    INFANTS. 

giving  rise  to  the  formation  of  a  pellicle  which,  projected  by  the 
exhaled  blood  on  the  inflamed  surface,  gives  to  a  certain  extent 
the  aspect  of  an  eschar.  Before  pronouncing,  therefore,  these  es- 
chars to  be  gangrenous,  the  nature  and  causes  of  the  brown  scabs 
covering  the  aphthous  ulcerations  should  be  examined  with  the 
closest  attention.  This  mistake  might  produce  fatal  consequen- 
ces, for  it  is  probable  that  the  idea  may  be  conceived  of  treating 
with  stimulants  and  tonics  a  disease  which  it  would  be  more  ra- 
tional to  treat  with  simple  antiphlogistic  means. 

Yet  I  do  not  deny  that  the  ulcerated  follicles  of  the  mouth  may 
sometimes  terminate  in  gangrene.  I  would  only  remark,  that 
this  termination  is  much  less  rare  than  Van  Swieten,  Rosen,  Un- 
derwood, and  many  others  appeared  to  have  believed.  When 
the  inflammation  lessens,  or  when  it  yields  to  the  means  employ- 
ed for  its  relief,  the  ulcer,  on  cicatrizing,  scarcely  ever  leaves  a 
sensible  trace  ;  its  apparent  depth  arises  also  from  the  thi<:jkness 
of  its  inflamed  and  tumefied  borders. 

Thus,  then,  aphthse  of  the  mouth  may  present  two  stages  in 
their  inflammatory  development ;  or  they  may  either  consist  of 
small  white  miliary  tumors,  or  these  tumors  may  ulcerate  and 
become  disorganized.  Now  it  results  from  this,  besides  being 
dictated  and  supported  by  observation,  that  aphthae  are  neither  tu- 
mors, as  some  will  say,  nor  ulcers,  as  is  thought  by  others  ;  but 
sometimes  one  and  sometimes  the  other  of  these  pathological  al- 
terations, according  as  the  degree  of  inflammation  is  more  or 
less  advanced.  If  occasionally  the  ulcer  alone  is  observed,  it  is 
because  the  primitive  development  of  the  follicle  had  escaped  the 
attention  of  the  physician,  or  of  those  having  charge  of  the  pa- 
tient. 

Callisen  has  well  described  aphthas,  and  has  considered  them  in 
a  manner  analogous  to  that  we  have  adopted.  The  description 
which  Plenck  has  given  of  them,  approaches  still  more  to  ours, 
except  that  he  regards  as  vesicles,  accidentally  formed,  the  small 
tumors  which  we  consider  as  a  morbid  development  of  muci- 
parous follicles.  "  Incipiunt  aphth(B  sub  forma  vesiciilarn7Ji  mi- 
Uariim  albantjii  qace  in  apice  foraminulum  gerunt,  deiti  colla^ 
hunter  et  aliquantitm  latescunt.^'* 

*  Doctrina  de  morbis  cutaneis. 


ON    THE    DISEASES    OF    INFANTS.  .  175 

The  analogy  which  some  have  thought  exists  between  the 
small  tumors  of  the  mouth  and  those  which  are  observed  on  the 
skin  in  some  cutaneous  phlegmasisD,  has  caused  a  comparison  to 
be  made  between  aphthse  and  miliary  eruption.*  But  this  com- 
parison has  no  foundation,  if  it  be  true  that  aphthae  are  owing  to  a 
tumefaction  of  the  muciparous  follicles.  There  cannot  really  be 
any  comparison  between  them  and  the  vesicles  of  miliary  erup- 
tion, from  which  they  essentially  differ. 

Finally,  the  aphthous  ulcerations .  differ  still  from  the  other 
ulcerations  of  the  mouth,  and  which  will  be  hereafter  noticed^ 

Since  we  are  now  in  possession  of  some  of  the  data  upon  the 
nature  and  development  of  aphthas,  let  us  see  what  are  the  causes, 
general  symptoms,  complications,  and  treatment  of  this  disease. 

This  is  not  a  disease  peculiar  to  infants,  for  adults  are  also  lia- 
ble to  them.  Froni  this,  doubtless,  arises  the  division  of  Bate- 
man,  Aphtha  lactantkim^  Aphtha  adultornm.  They  are  particu- 
larly to  be  seen  in  children  who  are  very  feeble,  pale,  and  of  a 
lymphatic  temperament.  We  do  not  look  for  the  causes,  of  aph- 
thae in  the  retention  of  the  meconium,  acidity  of  the  milk,  or  in 
the  predominance  of  acidity  in  the  fluids  of  the  child;  we  at- 
tach more  importance  to  the  consideration  of  the  original  pre- 
dominance of  the  lymphatic  system,  or  rather  to  the  remarkable 
predominance  which  this  system  acquires  under  the  influence  of 
bad  nutrition  and  vitiated  air,  which  is  respired  in  badly  ventilat- 
ed places,  in  those  who  are  crowded  together  with  a  number 
of  sick  children.  This  is,  in  truth,  the  result  of  the  researches 
and  reflections  of  Raulin,  Lapoyrenie,  Baudelocque,  Auvity,  M. 
Sanponts,  and  many  others.  It  will  appear,  then,  that  the  folli- 
cular apparatus  of  the  intestinal  tube  acquires  an  increased  vital 
energy  with  the  lymphatic  system ;  hence  this  disposition  of  in- 
fants to  inflammation  of  the  follicles,  and  to  the  alterations  which 
follow  in  the  different  parts  of  the  digestive  tube. 

I  have  observed  in  the  Hospice  des  Enfans  Trouves,  that 
while  muguet  prevails  almost  universally  among  children  re- 
cently born,  aphthae,  on  the  contrary,  are  more  frequently  observ- 
ed in  such  as  are  teething.  M.  Denis,  who  denominates  these 
aphthag  ulcerated  phlyctenae,  has  also  remarked  that  aphthae  are 

*  Van  Swieten,  Boerhaave,  Sauvage,  Arneman,  Willan,  Bateman,  etc. 


176  ON   THE    DISEASES   OF    INFANTS. 

not  developed  as  often  in  very  young  infants.*  Now  if  we  follow 
the  anatomical  development  of  the  lymphatic  glands  and  follicu- 
lar apparatus  of  the  digestive  tube  of  a  young  infant,  it  will  be 
seen  that  these  glands,  scarcely  formed  at  first,  grow  rapidly  in 
the  first  four  or  five  months ;  so  that  the  development  of  the 
lymphatic  system,  drawing  with  it,  as  we  may  say,  all  the  ap- 
pended parts,  impresses  on  the  constitution  of  the  child  a  pecu- 
liar idiosyncrasy,  from  which  results  a  predisposition  to  phleg- 
masias  of  the  follicles  and  muciparous  glands.  Thus,  anatomical 
and  pathological  observations  are  here  found  to  agree,  and 
throughout  the  whole  of  this  work  they  will  be  found  to  aiforda 
mutual  support  to  the  opinions  which  I  shall  endeavor  to  es- 
tablish. 

I  will  recapitulate  the  first  observations  by  remarking,  that  the 
principal  cause  of  aphthae  lies  in  the  anatomical  development  and 
increased  vital  energy  of  the  follicular  apparatus,  while  other 
causes  of  an  external  nature  excite  and  promote  the  development. 

The  general  symptoms  are  often  of  little  moment.  For  the 
most  part,  the  child  has  no  febrile  action.  The  skin  is  hot  and 
dry,  but  the  pulse  beats  with  the  greatest  tranquillity.  In  twelve 
children  affected  with  aphthae,  I  found  but  sixty  or  eighty  pulsa- 
tions, which  certainly  indicates  the  absence  of  any  febrile  action. 
This  remark  has  been  for  a  long  time  made  by  those  physicians 
who  have  attended  to  infantile  diseases.  Underwood  says,  "  The 
thrush,  in  its  commencement,  is  said  to  be  generally  attended 
with  fever;  but  those  who  have  been  of  this  opinion  do  not 
seem  to  have  made  what  is  a  very  necessary  distinction  ;  since  I 
have  by  no  means  found  this  to  be  the  case  when  the  thrush  is 
an  original  disease,  though  the  mouth  is  so  much  heated  as  to 
excoriate  the  nipples  of  the  nurse,  and  become  so  tender  that  the 
child  is  often  observed  to  suck  with  reluctance  and  caution." t 

Fever  does  not  show  itself  in  children  affected  with  aphthae,  un- 
til they  are  a  little  advanced  in  age,  and  even  then  all  may  not 
experience  it.  This  remark,  which  I  make  by  the  way,  is  wor- 
thy of  the  attention  of  physicians,  for  its  application  will  be  found 
in  the  history  of  general  pathology.     Indeed,  was  it  not  from  the 

*  Researches  (T anatomic  et  de  physiologie  pathologiques  sur  plusieurs  maladies  de» 
enfans  nouveau-nes,  Commerce,  1826. 

t  Treatise  on  the  Diseases  of  Children,  by  Underwood,  p.  35. 


ON   THE    DISEASES   OF   INFANTS.  177 

peculiar  alteration  of  the  mucous  membrane  of  the  alimentary  ca- 
nal, that  the  celebrated  Pinel  gave  the  name  of  mucous  fever  to 
one  of  his  essential  fevers?  But  if  this  alteration  can  exist  with- 
out fever,  as  is  the  case  in  very  young  children,  the  seat  and 
cause  of  the  fever  must  be  in  some  other  part  than  in  the  altera- 
tion of  which  the  fever  is  but  a  possible  and  not  a  necessary  nor 
constant  symptom.  Yet  M.  Pinel  insists  much  upon  this  lesion, 
and  upon  the  anatomical  characters,  as  one  of  the  principal 
points  among  the  lesions  observed  on  the  dead  bodies  of  those 
who  have  died  in  the  different  epidemics  of  mucous  fever.  The 
state  of  the  mouth,  oesophagus,  stomach,  and  intestines,  says  he,  is 
particularly  worthy  of  notice  in  the  affection  of  the  mucous  mem- 
brane of  these  parts.  Nothing  has  been  more  common  than  to 
find  aphthae  in  the  pharynx — that  is  to  say,  a  detachment,  in  cer 
tain  places  of  the  epidermis  which  covers  the  mucous  membrane.* 
It  is  true  that  there  exists,  at  the  same  time,  in  these  patients,  a 
similar  alteration  of  the  follicular  apparatus  of  the  intestines;  but 
we  can  point  out  cases  resembling  these  in  young  infants  who 
have  not  experienced  any  febrile  symptom.  We  will  note  this 
fact  now,  and  examine  it  more  fully  hereafter. 

When  the  aphtha3  are  small  in  number,  a  few  consecutive 
symptoms  present  themselves  ;  but  this  is  not  the  case  when  they 
are  confluent.  The  child  is  then  pale,  quickly  becomes  thin,  has 
a  diarrhoea  more  or  less  copious,  and  vomits  every  thing  that  is 
given.  These  occur  when  the  disease  has  spread  to  the  oeso- 
phagus, stomach,  and  intestines — the  most  frequent  and  fatal 
complications.  There  are  also  often  seen  regurgitations  and 
eructations  which  diffuse  an  acid  odor,  attributed  to  the  milk 
with  which  the  child  is  fed,  or  which  it  sucks,  not  being  digest- 
ed by  the  diseased  stomach.  This  acid  odor  is  analogous  in  re- 
spect to  that  of  milk  changed  by  heat  or  vinegar.  It  appears  to 
me  more  rational  thus  to  explain  the  acid  odor  of  the  matters 
vomited  or  voided  by  the  child,  than  to  seek  for  causes  in  the 
acid  or  alkaline  nature  of  the  fluids,  explanations  which  are  not 
adopted  at  the  present  day.  Is  it  to  the  acidity  of  the  humors 
that  the  acid  odor  of  the  indigestible  substances  vomited  by  one 


*  Nosogr.philos.t.  l.p.  130. 
23 


178  ON   THE    DISEASES    OF    INFANTS. 

who  has  indulged  in  too  copious  a  dinner,  or  who  has  been  jolt- 
ed in  a  carriage,  or  rolled  in  a  ship,  is  to  be  attributed  ? 

If  one  may  judge  from  the  cries,  wakefulness,  and  restlessness 
observed  in  children  affected  with  aphthae,  this  disease  is  not  with- 
out pain.  When  the  inflammation  is  propagated  to  the  pharynx, 
and  produces  a  swelling  of  the  glands  and  an  inflammation  of 
the  trachea,  the  cry  of  the  child  is  sensibly  altered,  and  it  is 
doubtless  as  Gardien  observes,  that  children  manifest  their  pain 
sooner  by  the  harsh  or  hissing  cry  than  by  their  tears.*  I  shall 
hereafter  examine  the  question  of  the  existence  of  aphthae  in  the 
trachea. 

Treatment. — The  therapeutic  means  advised  by  authors,  in 
the  treatment  of  aphthae  of  the  mouth,  have  varied  according  to 
the  particular  opinion  of  each  upon  the  nature  of  the  disease. 
For  our  part,  seeing  nothing  more  in  it  than  an  inflammation  of 
the  follicular  apparatus  of  the  mucous  membrane  of  the  mouth,  we 
advise,  in  the  first  place,  an  antiphlogistic  course.  Yet  as  there 
are  among  the  means  advised,  according  to  particular  views, 
some  medical  agents  capable  of  advantageously  modifying  and 
overcoming  this  inflammation,  we  will  but  perform  our  duty  in 
pointing  them  out. 

When  aphthae  exist  in  a  mild  form,  it  will  be  necessary  to  wash 
the  mouth  with  a  piece  of  lint  dipped  in  a  decoction  of  marshmal- 
lows,  barley-water,  or  milk  and  water.  The  vapor  from  a  decoc- 
tion of  marshmallows  or  simple  water,  is  also  a  useful  remedy. 

The  general  condition  of  the  constitution  of  the  child,  and  its 
causes,  unhealthy  air  and  bad  diet,  should  be  borne  in  mind. 
We  often  see  infants  artificially  fed,  suddenly  acquire  a  good 
condition  upon  being  placed  in  the  care  of  a  good  nurse,  and  al- 
ter from  a  state  of  weakness  and  decay  to  which  they  had  been 
reduced  by  insufficient  or  bad  food ;  it  will  be  necessary  then  to 
remove  from  infants  affected  with  aphthae,  all  the  causes  capable 
of  favoring  in  them  the  predominance  of  the  lymphatic  system, 
in  having,  at  all  times,  a  proper  regard  for  the  condition  of  the 
digestive  organs,  and  not  irritating  them  by  the  internal  adminis- 
tration of  tonics. 

When  the  aphthae  remain  stationary,  or  are  confluent,  and  re- 

♦  Traite  complet  d^accouchemens,  etc.,  t.  4. 


ON    THE    DISEASES    OF    INFANTS.  179 

sist  simple  antiphlogistic  means,  then  it  would  be  well  to  sub- 
stitute acidulated  gargles  for  emollient  drinks.  A  mixture  of 
barley-water  and  honey  of  roses,  with  a  few  drops  of  sulphuric 
acid,  may  also  be  used  with  benefit.  In  order  to  change  the 
mode  of  irritation,  and  to  dispose  the  inflamed  surfaces  to  cica- 
trize, it  will  be  advantageous  sometimes  to  touch  the  ulcerated 
part  with  a  piece  of  alum.  Aretaeus  long  since  advised  the  use 
of  alum  as  a  topical  application,  in  the  treatment  of  chronic  m 
flammation  of  the  mouth  and  throat.  It  should  always  be  used 
with  caution,  and  employed  alternately  with  demulcent  gargles 
and  no  irritation  produced  beyond  what  we  wish  to  obtain  by 
this  therapeutic  agent. 

I  will  not  speak  of  other  stimulating  means,  such  as  borax, 
sulphate  of  zinc,  etc.,  because  alum,  which  is  innocent  if  cautious- 
ly used,  will  accomplish  the  same  end.  Gargling  with  chloride 
of  soda,  as  advised  by  Guersent  in  muguet,  should  not  be  neglect- 
ed in  this  disease. 

If  the  child,  by  its  cries,  gives  evidence  of  excessive  pain,  a 
little  syrup  of  poppies  ought  to  be  added  to  the  gargles,  in  the  pro- 
portion of  one  to  two  drachms  to  two  ounces  of  mucilage  or  gum- 
water.  As  to  tonics,  emetics,  and  purgatives,  it  appears  impossi- 
ble, by  the  internal  use  of  them,  to  obtain  any  exclusive  or  gene 
ral  result.  We  will  return  to  the  consideration  of  their  employ- 
ment, when  the  history  of  the  phlegmasiae  of  the  digestive  tube 
becomes  the  subject  of  our  remarks,  when  this  complication 
will  be  examined.  If  aphthae  should  become  gangrenous,  the 
treatment  recommended  in  the  article  on  gangrenous  stomatitis, 
must  then  be  adopted.  If  they  are  complicated  with  a  cutaneous 
affection,  we  should  endeavor  to  ascertain  and  establish  its  char- 
acters, in  order  to  treat  it  according  to  its  nature,  progress,  and 
the  indications  it  presents.* 

ULCEROUS    STOMATITIS. 

Besides  the  ulcerations  which  succeed  the  disorganization  of 
the  follicles,  there  often  exist  both  in  new-born  infants  and  in 
those  a  little  advanced  in  age,  ulcerations  in  the  mouth  of  a  dif- 
ferent character.     These  ulcers  occupy  indifferently  every  part 


See  Appendix,  page  569. 


180  ON   THE    DISEASES    OP    INFANTS. 

of  the  buccal  cavity.  I  have  seen  them  on  the  frcenum  of  the 
tongue,  at  its  base,  and  on  the  internal  surface  of  the  cheeks,  and 
on  the  palatine  arch ;  they  may  occur  in  different  ways.  As 
these  ulcerations  have  been,  and  still  are,  confounded  with  aph- 
thae, I  think  it  will  be  well  to  begin  their  history  by  the  detail  of 
a  few  cases. 

CASE  X. — Gastro-enteritiSf  ulcer  at  the  base  of  the  tongue. — 
Chabert,  a  male  child,  aged  eleven  days,  of  strong  constitution,  but 
pale,  and  a  little  emaciated,  entered  the  infirmary  on  the  tenth  of 
April,  1826.  He  had  a  slight  coryza,  and  a  diarrhoea  of  green  dis- 
charges. The  abdomen  was  distended  with  gas ;  there  was  no  fe- 
ver. A  tisan  of  rice,  and  injections  of  starch  were  administered. 
On  the  thirteenth,  the  diarrhoea  ceased ;  the  buccal  membrane  be- 
came red  and  dry ;  the  tongue  exhibited  at  the  base  a  sensible  tume- 
faction ;  the  cry  of  the  child  was  painful  without  any  alteration  in 
the  tone.  (Gummed  rice  water,  emollient  gargles.)  On  the  fifteenth 
the  diarrhoea  returned  with  increased  violence.  The  discharges 
were  no  longer  green,  but  were  liquid,  frothy,  and  white.  The  child 
soon  became  atrophied  ;  the  centre  of  the  tumefaction  at  the  base  of 
the  tongue  softened,  and  became  yellow.  On  the  sixteenth,  emacia- 
tion had  made  great  progress ;  the  pulse  was  feeble ;  the  skin  dis- 
colored and  dry,  the  inferior  extremities  were  infiltrated,  the  abdo- 
men very  much  distended,  the  diarrhoea  continued,  and  the  base  of 
the  tongue  exhibited  an  elliptical  ulceration,  the  borders  of  which 
were  depressed,  and  the  centre  red  and  sanguinolent.  This  ulcera- 
tion spread  more  particularly  towards  the  left  lateral  portion  of  the 
base  of  the  tongue.  (Gummed  rice  water,  starch  injections,  emol- 
lient gargles.)     The  child  died  during  the  night. 

Post  mortem  examination. — (Esophagus  healthy ;  stomach  con- 
tracted, with  red  points  and  ridges  on  its  surface ;  small  intestines 
healthy,  but  the  large  presented  a  general  discoloration  and  soften- 
ing of  their  internal  membrane.  The  circulatory  and  sensitive  ap- 
paratus were  healthy. 

This  ulceration  was  doubtless  caused  by  acute  inflammation 
of  the  membrane  of  the  tongue,  and  differed  essentially  from  the 
ulcer  arising  after  aphthae. 

CASE  XL — Ulcer  of  the  arch  of  the  palate. — Derpois,  a  boy  aged 
nineteen  days,  entered  the  infirmary  on  the  1st  of  February,  1826. 


ON   THE    DISEASES    OF    INFANTS.  181 

This  child  was  small,  thin,  and  pale  ;  his  skin  hot,  and  pulse  scarcely 
perceptible  ;  his  tongue  very  red  at  the  extremity,  but  was  white  at 
the  base ;  there  was  a  slight  tumefaction  of  the  abdomen,  copious 
diarrhoea,  and  frequent  vomiting.  {Gummed  rice  water,  cataplasm 
to  the  abdomen.)  On  the  4th  of  February,  the  mucous  meptibrane 
of  the  arch  of  the  palate  became  tumefied,  and  very  red  at  a  circum- 
scribed point ;  the  general  condition  of  the  child  was  not  altered. 
{Same  treatment,  emollient  gargles.)  On  the  8th,  the  diarrhoea  in- 
creased ;  the  child  was  excessively  pale,  slightly  agitated,  often 
drowsy,  and  had  rapidly  become  emaciated  ;  the  mucous  membrane 
of  the  mouth  presented  an  irregularly  rounded  ulceration  ;  its  edges 
were  tumefied,  hard,  and  red,  and  the  centre  yellow ;  the  centre  was 
about  two  lines  in  diameter.  On  the  12th,  same  condition ;  the  ulcer 
remained  indolent;  nothing  used  but  a  wash  of  marshmallows. 
The  child  vomited  almost  every  thing  that  was  given.  On  the  16th 
he  died. 

Post  mortem  examination. — Complete  marasmus,  and  an  exsan- 
guined  state  of  the  integuments.  The  mouth  exhibited,  besides  the 
ulceration  mentioned,  an  intense  redness  of  every  part  of  the  buccal 
membrane,  and  a  very  strongly  marked  tumefaction  existed  at  the 
base  of  the  tongue  and  the  lateral  parts  of  the  pharynx.  The  oeso- 
phagus was  injected  ;  the  internal  surface  of  the  stomach,  which  con- 
tained coagulated  milk,  exhibited  a  rosy  hue  ;  the  duodenum  was 
healthy.  From  the  middle  of  the  jejunum  to  the  ileo-ccecal  valve,  the 
internal  membrane  of  the  intestine  was  of  a  deep  red,  tumefied,  and 
friable  ;  towards  the  extremity  of  the  ileon  it  was  less  red,  but  it  was 
in  a  pulpy,  softened  condition.  The  large  intestines  were  healthy. 
The  other  organs  presented  nothing  remarkable. 

The  ulceration  in  this  instance  was  much  more  advanced  than 
in  the  preceding  case.  It  was  evidently  the  result  of  inflamma- 
tion of  the  buccal  membrane,  which  was  found  very  much  in- 
flamed, particularly  about  the  pharynx. 

In  dissecting  the  body  of  a  child,  whose  case  I  had  not  exam- 
ined during  life,  I  found  upon  the  internal  surface  of  the  lower 
lip,  and  on  its  left  side,  a  large  superficial  ulceration,  the  irregu- 
lar edges  of  which  were  tumefied,  and  upon  the  sides  a  curdy 
excretion,  analogous  to  that  sometimes  seen  in  aphthae.  I  have 
often  seen  the  froenum  of  the  tongue  destroyed  by  similar  ulcers, 
cases  of  which  I  shall  give  hereafter.     Denis  has   observed  a 


182  ON  THE  DISEASES  OP  INFANTS. 

softening  of  the  mucous  membrane  of  the  palate,  which,  accord- 
ing to  this  author,  almost  always  occupies  the  centre  of  the  pa- 
late, on  the  median  line.  Sometimes  it  is  situated  on  the  outside 
of  this  line  ;  the  mucous  membrane,  red,  inclining  to  a  fawn  co- 
lor, is  changed  to  a  kind  of  pulp.  If  it  be  raised,  it  will  be  ob- 
served that  the  edges  of  the  ulceration  are  perpendicular,  and 
that  the  bottom  of  the  ulcer  is  formed  of  the  bone  apparently  in 
a  healthy  condition.*  M.  Baron  has  told  me  that  he  has  several 
times  seen  this  disorganization,  an  affection  which  I  have  not  as 
yet  happened  to  meet. 

The  treatment  of  these  ulcerations  differs  but  little  from  that 
of  aphthae  ;  when  they  resist  the  use  of  emollient  gargles,  and 
continue  to  increase,  we  should  then  endeavor  to  arrest  their  ra- 
vages by  touching  them  with  mild  escharotics ;  and  if  they  ter- 
minate in  gangrene,  recourse  must  be  had  to  the  active  measures 
pointed  out  hereafter. 

The  softening  of  the  mucous  membrane  is  a  very  serious  alter- 
atiouj  and  one  which  I  believe  it  is  impossible  to  remedy. 

PUSTULAR    STOMATITIS. 

I  give  this  name  to  the  inflammation  which  is  developed  during 
the  course  of  small-pox,  producing  pustules  analogous  to  those 
on  the  skin.  As  it  presents  no  particular  indication,  and  as  the 
treatment  is  comprehended  in  that  of  the  cutaneous  phlegmasiee, 
T  merely  mention  here  this  variety  of  buccal  inflammation,  the 
development,  progress,  and  termination  of  which  is  connected 
with  the  development  and  progress  of  variola. 

I  have  not  been  able  to  establish  exactly  the  seat  of  this  alter- 
ation, which,  from  the  analogy  it  bears  to  the  cutaneous  inflam- 
mation accompanying  it,  I  regard  as  pustular. 

GANGRENOUS    STOMATITIS. 

Gangrene  of  the  mucous  membrane  of  the  mouth,  may  occur 
in  various  ways.  It  may  be  the  termination  of  the  various  kinds 
of  stomatitis  already  described,  but  particularly  of  the  follicular 
variety.  It  may  be  developed  as  an  effect  of  some  particular  al- 
teration arising,  in  the  first  place,  in  the  soft  parts  of  the  buccal  pa- 

*  Denis,  loc.  cit,  p.  109. 


ON   THE    DISEASES   OP    INFANTS.  183 

rieteSj  the  causes  and  nature  of  which  we  will  endeavor  to 
state. 

Gangrene  which  shows  itself  on  the  ulcerated  points  of  the 
mouth,  has  been  pointed  out  by  a  number  of  authors.  This  is 
what  is  ordinarily  designated  by  the  name  gangrenous  aphthye.  I 
believe  also  that  aphthee  have  been  sometimes  regarded  as  gan- 
grenous when  they  were  not  so,  as  has  already  been  observed. 

When  aphthae  become  gangrenous,  their  edges  shrink  and  as- 
sume a  burned,  torn,  and  flabby  aspect ;  then  a  brown  eschar 
often  forms  in  the  centre,  which  soon  detaches  itself,  leaving  a 
granulated  surface  of  a  vermilion  color.  In  place  of  an  eschar, 
the  centre  of  the  ulcer  sometimes  gives  off  a  creamy  substance 
of  a  brown  color,  and  of  a  very  evident  gangrenous  odor.  The 
surrounding  parts  tumefy,  assume  a  violet  aspect,  become  softer, 
and  are  easily  depressed.  In  the  mean  time,  from  the  mouth  of 
the  child,  always  half  open,  there  flows  a  ropy  saliva.  The  face 
becomes  pale ;  the  patient  remains  drowsy,  and  sinks  without 
having  exhibited  any  febrile  reaction  or  cerebral  excitation.  The 
pulse  remains  always  extremely  feeble,  and  the  skin  is  remarka- 
ble for  its  pallidness  and  insensibility.  To  these  symptoms  there 
are  often  added  vomiting,  diarrhoea,  and  distention  of  the  abdo- 
men, and  sometimes  hiccup  and  frequent  eructations. 

This  termination  of  aphthae  is  extremely  fatal,  for  it  happens 
usually  at  a  period  when  the  child,  wasted  by  the  previous 
phlegmasia  with  which  it  was  affected,  affords  no  opportunity  for 
the  administration  of  therapeutic  agents  demanded  by  its  situation. 

As  soon  as  the  gangrene  is  formed,  it  will  be  necessary  to 
touch  it  with  gum-water,  slightly  acidulated.  Should  this  appli- 
cation effect  no  alteration  in  the  aspect  of  the  ulcer,  sulphuric  or 
muriatic  acid  must  be  used.  In  order  to  apply  them  in  the 
easiest  manner,  a  glass  capillary  tube  may  be  used,  immersing 
one  end  in  the  acid,  and  drawing  up  one  or  two  drops,  which 
may  afterwards  be  deposited  on  the  surface  of  the  ulcer,  with  the 
end  of  the  tube.  After  the  application  of  these  acids,  and  when 
the  eschar  is  detached,  it  will  be  necessary  to  touch  the  remain- 
ing gangrenous  parts  with  a  stick  of  nitrate  of  silver,  sharpened 
at  the  point ;  for  by  using  the  acid  again,  it  might  touch  the 
parts  deprived  of  the  eschar,  and  which  are  then  in  a  state  of  ex- 
treme irritability.     It  is  much  easier  to   moderate  and  limit  at 


184  ON  THE   DISEASES  OP   INFANTS. 

will  the  action  of  nitrate  of  silver,  which  however  does  not  act 
very  deeply  if  it  be  used  at  first. 

Our  remarks  on  gangrenous  aphthae,  apply  to  all  ulcers  of  the 
mouth  which  assume  that  character. 

I  shall  now  consider  gangrene  of  the  mouth  properly  so  called, 
that  which  does  not  follow  any  well  characterized  inflammation, 
but  appears  to  be  brought  about  by  some  particular  alteration  of 
the  parietes  of  the  mouth. 

This  disease  has,  for  a  long  time,  attracted  the  attention  of  the 
physicians  ;  but  it  is  not  until  quite  recently  that  it  has  been  stu- 
died with  much  attention,  and  it  is  to  the  works  of  MM.  Baron, 
Guersent,  Jadelot,  and  Isnard,*  that  we  are  indebted  for  positive 
data  on  this  disease.  When  the  commentaries  of  Van  Swieten 
on  the  aphorisms  of  Boerhaave  are  examined,  it  will  be  seen  that 
this  physician  has  spoken  particularly  of  the  destruction  of  the 
tissues  of  the  gums  by  gangrene  or  softening,  an  alteration  which 
will  be  examined  below,  and  that  he  has  not  described  with  pre- 
cision the  gangrene  of  the  mouth,  as  we,  at  the  present  day,  un- 
derstand by  the  disease,  and  as  is  described  in  the  works  of  the 
authors  above  mentioned.  Van  Swieten  says,  "  >S'i  autem  mul- 
turn  tumeat  gingiva^  simulque  admodum,  rubeatj  validcB,  in- 
fiartimationis  signum  est  quemadmodnm  in  gangrcBmim  satis 
cito  terminatur,  precipue  si  acrior  huniorum  indoles  simul 
adsitJ^t  In  gangrene  of  the  mouth,  which  we  propose  to  de- 
scribe, not  only  may  there  be  destruction  of  the  gums,  but  also  of 
the  mucous  membrane  of  the  parietes  of  the  mouth,  in  every  part 
of  this  cavity. 

In  studying  this  affection,  we  must  not  confine  ourselves  sole- 
ly to  the  time  of  the  appearance  of  the  eschar  or  point  of  disor- 
ganization, which  constitutes  the  principal  characters  of  thi^  dis- 
ease. It  is  necessary  to  ascend  higher,  and  to  examine  well  the 
morbid  condition  which  precedes  and  leads  to  the  gangrene. 

We  have  seen,  in  treating  of  the  diseases  of  the  skin,  that  in 
young  infants,  the  feet,  hands,  and  labia  pudendi,  were  subject  to 
indolent  swellings,  which  frequently,  in  place  of  disappearing, 

♦  Baron,  Mem.  sur  une  affection  gangrmeuse  de  la  bouche.  Bulletins  de  la  faxjul- 
te.  Isnard,  Dissertation  sur  une  affection  gangreneuse  particuliere  aux  enfans. 
Paris,  1818. 

t  Van  Swieten,  in  Boerhaave  Aphor.  com.  morhi  infantum^  t.  4. 


ON    THE    DISEASES    OF    INFANTS.  185 

terminate  in  gangrene.  The  same  phenomenon  occurs  at  the 
anterior  orifice  and  at  the  parietes  of  the  mouth  of  some  infants. 
Indeed  those  children  that  are  born  feeble,  and  in  a  kind  of  stu- 
por which  denotes  a  low  degree  of  vital  energy,  often  exhibit 
indolent  swellings,  of  which  the  following  case  will  furnish  an 
example. 

CASE  XII. — Adele  Montaban,  aged  one  month,  has  been  nursed 
at  the  hospital  from  birth  ;  was  of  a  very  feeble  constitution  ;  color 
pale,  abdomen  habitually  distended  ;  and  she  vomited  the  milk  she 
had  taken.  She  entered  the  infirmary  on  the  4th  of  February, 
1826.  Besides  the  signs  already  indicated,  she  presented  the  fol- 
lowing symptoms :  the  drinks  vomited  shortly  after  being  taken  ; 
edges  of  the  tongue  red ;  abdomen  tympanitic  ;  diarrhoea  of  yellow 
discharges  ;  redness  about  the  anus.  [Gummed  rice  water,  emol- 
lient fomentations  to  the  abdomen,  milk  and  water,)  She  continued 
for  eight  days  in  the  same  condition.  On  the  twelfth,  some  spots  of 
muguet  appeared  on  the  surface  of  the  tongue ;  emaciation  made  ra- 
pid progress  ;  the  child  exhibited  a  chlorotic  paleness ;  and  the  face 
was  swelled  and  infiltrated.  On  the  fifteenth,  infiltration  of  the  face 
had  much  increased,  and  a  well-marked  tumefaction  of  the  upper  lip 
was  also  observed,  which  was  thereby  half  raised,  leaving  the  mouth 
partly  open  ;  the  eyelids  also  were  slightly  cedematous.  The  gene- 
ral condition  of  this  child  was  remarkable  for  nothing  except  the  uni- 
versal sinking  and  prostration  which  it  presented  ;  there  existed  no 
febrile  action.  {Gummed  rice  vcater,  milk  and  water.)  On  the 
eighteenth,  the  diarrhoea  and  vomiting  had  ceased  ;  the  face  and  lip 
in  the  same  condition.  On  the  twentieth,  the  tumefaction  of  the  up- 
per lip  was  much  greater,  the  border  of  which  had  become  of  a  vio- 
let color  ;  general  coldness  ;  the  cry,  which  before  had  been  feeble, 
was  not  now  heard  ;  the  pulsations  of  the  heart  were  very  slow^ 
irregular,  and  trembling ;  the  child  died  on  the  night  of  the  twen- 
tieth. 

Post  mortem  examination. — Upon  dissecting  the  upper  lip,  there 
was  found  a  citron-colored  serum  mixed  with  drops  of  blood,  infil- 
trated through  the  subcutaneous  cellular  tissue  ;  the  membrane  on  a 
level  with  this  part  was  tumefied  and  very  soft ;  the  inferior  lip  also 
presented  a  slight  cedematous  tumefaction.  On  the  froenum  of  the 
tongue  there  was  a  superficial  ulcer,  which  had  not  been  observed 
during  life.     The  glottis  was  the  seat  of  an  cedematous  swelling,  and 

the  oesophagus  that  of  a  sanguineous  congestion.     The  stomach  was 

24 


186  ON   THE    DISEASES    OF    INFANTS. 

healthy ;  the  duodenum,  which  contained  a  viscid  fluid  of  the  color 
of  bistre,  exhibited  a  number  of  red  striae.  The  remainder  of  the 
small  intestines  were  only  of  a  slight  rose  color  ;  yet  the  internal 
membrane  was  tumefied  and  friable.  The  colon  presented  some 
red  striae,  and  between  them,  several  of  a  slate  color.  The  liver  and 
the  two  lungs  were  gorged  with  blood.  The  foramen  ovale  was  still 
open,  but  the  ductus  arteriosus  obliterated.  The  vessels  of  the  peri- 
phery of  the  brain  were  engorged,  the  ventricles  containing  but  little 
serosity. 

This  case  is  remarkable,  inasmuch  as  the  external  condition 
of  this  child,  the  paleness  and  sinking,  appeared  to  indicate  the 
employment  of  tonics,  which  must  have  been  injurious  to  the  di- 
gestive passages  in  their  inflamed  condition.  Perhaps  this  ge- 
neral sinking  might  be  attributed  to  a  sanguineous  congestion  of 
the  principal  organs  of  the  circulatory  apparatus.  Be  this  as  it 
may,  we  ought  to  note  the  OBdematous  swelling  of  the  upper  lip, 
which,  if  the  death  of  the  child  had  not  occurred,  would  doubt- 
less have  led  to  the  disorganization  of  which  the  following  cases 
furnish  us  examples. 

CASE  XIII. — Rose  Camusot,  aged  twelve  days,  born  feeble  and 
wretched,  wasted  daily  while  in  charge  of  the  nurse  to  whom  she 
was  confided.  She  was  brought  to  the  infirmary  on  the  9th  of  July, 
1826.  She  was  pale,  cried  aloud,  and  was  at  times  drowsy.  The 
temperature  of  her  skin  was  natural ;  the  pulse  beat  from  seventy 
to  seventy-two  ;  the  pulsations  were  small  and  sometimes  indistinct. 
{Milk  and  water,  with  bar  ley -water.)  In  the  same  condition  until 
the  fifteenth.  Emaciation  then  advanced ;  great  paleness  ;  tongue 
very  red  and  dry,  and  covered  with  spots  of  muguet  at  the  edges. 
(Gargles  of  marshmallows,  milk  and  water.)  On  the  fifteenth,  the 
muguet  was  more  widely  spread  on  the  surface  of  the  tongue  ;  all  the 
lower  parts  of  the  face  were  oedematous,  and  the  lower  lip  became  the 
seat  of  a  considerable  tumefaction,  in  consequence  of  which  it  was 
turned  downward  ;  the  skin  covering  it  had  an  oily  appearance. 
The  mucous  membrane  was,  as  it  were,  ecchymosed  at  the  internal 
part  of  this  lip.  (Gargles  of  a  decoction  of  cinchona,  acidulated, 
milk  and  water.)  On  the  twentieth,  the  swelling  of  the  lip  had 
made  great  progress ;  a  large  violet  spot,  analogous  to  what  is 
known  by  the  name  of  naevus,  showed  itself  on  the  integuments  of 
the  lower  lip,  which    was  quite   hot  to  the  touch.     The  pulse  was 


ON   THE    DISEASES    OF    INF'ANTS.  1S7 

slow  and  almost  imperceptible.  The  child,  in  a  state  of  complete 
exhaustion,  had  neither  vomiting  nor  diarrhoea.  This  state  contin- 
ued until  the  twenty-second,  and  in  the  same  night  she  died. 

Post  mortem  examination. — When  the  lower  lip  was  dissected, 
an  infiltration  of  bloody  serum  was  found,  the  accumulation  of  which 
gave  to  the  tissue  of  the  lip  a  thickness  of  about  four  lines  ;  the  mu- 
cous membrane  began  to  detach  itself  on  the  internal  surface  of  the 
maxillary  bone.  But  slight  traces  of  muguet  continued  on  the 
tongue.  The  stomach  exhibited  a  violet  color  ;  the  internal  mem- 
brane was  tumefied  and  friable  ;  all  the  intestinal  tube  was  covered 
with  red  striae,  the  mesenteric  ganglia  were  redder  and  more  tume- 
fied than  in  the  natural  state.  The  lungs  were  healthy ;  the  ductus 
arteriosus  was  obliterated,  and  the  foramen  ovale  still  remained  a 
little  open  ;  the  brain  was  perfectly  healthy. 

We  have  seen  in  this  latter  child,  an  erosion  or  an  ulceration 
of  the  mucous  membrane  of  the  mouth  follow  the  oedematous  tu- 
mefaction of  which  the  walls  of  this  cavity  had,  for  some  days, 
been  the  seat.  We  shall  see,  in  the  following  case,  gangrene 
making  wide  spread  and  rapid  progress. 

CASE  XIV. — Delosane  (Victoire,)  aged  nine  days,  entered  the  in- 
firmary on  the  5th  of  January,  1826.  General  oedema  was  present ; 
color  of  the  integuments  of  a  medium  tint ;  pulse  full,  irregular,  and 
a  little  frequent ;  the  cry  but  little  developed,  and  possessing  a 
slight  huskiness  ;  the  chest,  on  percussion,  returned  an  obscure  sound 
on  the  right  side.  (Pectoral  infusion,  sweetened  milk  and  water.) 
From  the  fifth  to  the  eighth,  no  remarkable  change  was  manifested, 
except  that  emaciation  had  commenced.  On  the  eleventh,  the  left 
side  of  the  face  was  sensibly  swelled  ;  the  gums  of  the  same  side  tu- 
mefied ;  the  cry  was  feeble,  and  a  constant  discharge  of  a  mucous  san- 
guinolent  fluid  took  place  from  the  mouth.  There  was  not  the 
slightest  febrile  action.  (Sweetened  barley -water,  emollient  gar- 
gles.) On  the  twelfth,  the  swelling  of  the  face  had  made  frightful 
progress,  and  the  child  was  much  disfigured ;  the  cry  smothered  ; 
oedema  of  the  limbs  continued  ;  the  mouth,  which  was  almost  con- 
tinually filled  with  bloody  mucus,  emitted  an  odor  of  rotten  eggs. 
The  tumefaction  corresponding  with  the  gums,  had  not  made  as 
much  progress  as  that  of  the  face.  M.  Baron  directed  my  attention 
to  the  smooth  and  oily  aspect  of  the  oedematous  part  of  the  face ;  in 
the  middle  of  this  tumefaction  appeared  a  round  spot  about  the  size 


18S  ON  THE  DISEASES  OP   INFANTS. 

of  a  ten  sous  piece,  of  a  dull  red.  In  the  centre  of  the  cheek  was  a 
small  part  much  harder  than  the  other  parts.  (Acidulated  gargle, 
milk  and  water.)  On  the  thirteenth,  a  round  eschar,  brown  in  the 
centre,  and  yellow  at  the  borders,  appeared  at  the  internal  surface  of 
the  swelled  cheek,  and  extended  to  the  lower  part  of  the  gums,  near 
which  there  existed  a  deep  erosion,  the  edges  of  which  were  brown, 
and  appeared  as  if  burned.  It  exhaled  from  the  mouth  a  well-mark- 
ed gangrenous  odor.  The  red  spot  on  the  exterior  of  the  cheek  had 
assumed  a  violet  color.  The  child  was  much  sunken,  quiet,  and 
without  fever.  On  the  fourteenth,  the  eschar  was  enlarged  ;  it  had 
invaded  the  whole  of  the  cheek,  on  the  internal  surface  of  which  it 
was  soft,  brown,  and  surrounded  by  a  circle  of  a  violet  red.  The 
erosion  of  which  I  have  spoken,  was  replaced  by  a  sinus  of  some 
depth,  formed  by  the  sloughing  of  the  mucous  membrane.  From 
this  sinus,  there  issued  a  brown,  bloody,  viscid  matter.  The  child 
died  at  night. 

Post  mortem  examination, — The  face  still  presented  the  same 
cedematous  tumefaction  which  was  observed  during  life ;  the  eschar 
in  the  centre  of  the  cheek  was  of  the  consistence  of  cream,  and  se- 
parated in  shreds ;  the  tissue  of  the  cheeks  exhibited  a  lardaceous 
aspect ;  the  gums  were  entirely  destroyed  by  gangrene  at  the  cor- 
responding part  ;  the  inferior  maxillary  bone  was  bare;  the  oesopha- 
gus was  injected  ;  spots  of  red  were  found  in  the  stomach  ;  general 
injection  of  the  capillaries  of  the  small  intestines  ;  the  large  intestines 
were  healthy.  I  dissected  the  arteries,  veins,  and  nerves  going  to 
the  cheeks,  without  finding  any  thing  worthy  of  remark  in  them. 

There  were  also  solid  cellular  adhesions  between  the  pleura  cos- 
talis  and  pleura  pulmonaris  of  the  right  side  ;  the  lungs  of  this  side 
crepitated.  The  right  lung  was  much  infiltrated  with  blood  in  the 
inferior  lobe,  while  it  crepitated  at  the  superior  part. 

The  pericardium  was  a  little  distended,  and  contained  nearly  two 
spoonsful  of  puriform  serum  ;  the  internal  surface  of  the  pericardium 
exhibited  a  slight  red ;  the  membranous  covering  of  the  heart  was 
very  red,  and  was  spread  over  with  a  pseudo-membranous  exuda- 
tion about  the  thickness  of  letter-paper  ;  this  exudation  was  of 
greater  thickness  at  the  auricles  than  at  the  ventricles  ;  the  tissue  of 
the  heart  was  dense  and  very  pale ;  the  fcetal  openings  were  obliter- 
ated.    The  brain- exhibited  a  general  congestion. 

This  case  presents  several  interesting  points,  such  as  chronic 
pleurisy   and   acute  pericarditis  ;  but  in  order  to  confine  our- 


ON   THE    DISEASES    OF    INFANTS.  1S9 

selves  to  the  subject  before  us,  let  us  fix  our  attention  particularly 
on  the  progress  of  the  gangrene  of  the  mouth,  and  let  us  notice — 
1st,  The  (Edematous  swelling  of  the  cheek,  the  skin  of  which  had 
assumed  an  oily  aspect ;  2dly,  The  indurated  spot  which  showed 
itself  in  the  centre  of  the  engorgement,  and  which  without  doubt 
resulted  from  the  commencement  of  the  disorganization  of  the 
cellular  or  adipose  tissue ;  3dly,  The  muco-sanguinolent  dis- 
charge ;  4thly,  The  violet  spot  replaced  by  an  eschar ;  5thly, 
and  lastly,  The  extensive  disorganization  of  the  cheeks  and  of 
the  tissue  of  the  gums  in  the  spot  corresponding  with  the  eschar, 
which  had  presented  all  the  characters  of  gangrene,  and  which 
first  showed  itself  at  the  point  of  contact  of  the  buccal  parietes 
and  the. inferior  maxillary  bone. 

M.  Baron,  in  his  excellent  memoir  on  the  gangrene  of  the 
mouth,  inserted  in  the  Bulletins  de  la  Faculte  de  Medicine  de  Pa- 
ris, has  also  pointed  out  these  various  stages  of  the  disease  now 
under  consideration,  and  to  which  practitioners  ought  carefully  to 
direct  their  attention  ;  for  by  closely  observing  their  approach,  all 
the  evil  consequences  which  follow  may  be  prevented,  and  this 
disorganization  encountered  before  its  arrival  at  a  stage  which, 
for  the  most  part,  is  incurable  and  mortal. 

There  may  be  two  well-marked  stages  in  this  disease: — 1st, 
An  oedematous,  circumscribed  tumefaction,  characterized  by  an 
oily  aspect  of  the  skin,  and  by  a  central  body  more  or  less  hard, 
on  which  there  is  sometimes  an  obscure  red  spot,  either  on  the 
internal  or  external  surface  of  the  buccal  parietes  ;  this  is  the 
first  stage,  and  in  young  infants  is  not  accompanied  with  fever  or 
any  symptom  of  reaction  ;  2dly,  This  central  part  presents  an 
eschar  which  usually  forms  from  within,  the  mucous  membrane 
becomes  disorganized,  the  bones  are  laid  bare,  all  the  soft  parts, 
even  to  the  periosteum,  mortify  and  separate  in  shreds,  at  the 
same  time  that  the  mucous  or  bloody  matter,  mixed  with  the  re- 
mains of  the  gums  or  sides  of  the  mouth,  flows  out,  exhaling  an 
infectious  odor  ;  this  is  the  second  stage. 

Gangrene  of  the  mouth  must  not  be  confounded  with  malig- 
nant pustule,  for,  as  has  been  well  observed  by  Rayer,  the  gan- 
grenous inflammation  commences  in  the  interior  of  the  mouth, 
and  from  thence  spreads  to  the  skin.  There  is  nothing  to  prove 
the  contagiousness  of  this  disease  ;  it  is  usually  observed  in  one 


190  ON   THE    DISEASES    OP    INFANTS. 

patient  at  a  time,  in  an  hospital,  even  when  surrounded  by  num- 
bers of  other  children. 

It  is  difficult  to  explain  the  cause  of  this  gangrene ;  neverthe- 
less it  is  a  fact  which  ought  to  be  taken  into  consideration,  that 
osdema  and  indolent  tumefaction  always  precede  the  formation  of 
the  eschar.  Is  it  because  the  blood  no  longer  circulating  in  the 
capillary  vessels,  the  lymph  and  serum  engorge  and  spread 
through  the  cellular  tissue,  and  the  parts  which  the  blood  should 
nourish  become  thereby  disorganized?  I  cannot  answer  this 
question  positively ;  but  I  can  at  least  observe  that  this  gangrene, 
far  from  proceeding  from  inflammatory  action,  is,  on  the  contra- 
ry, the  result  of  an  indolent  engorgement,  analogous  to  that 
which  constitutes  anasarca.  In  the  latter  case,  the  parts  of  the 
body  which  are  compressed  readily  become  gangrenous ;  now 
the  internal  surface  of  the  mouth,  the  walls  of  which  are  thus  tu- 
mefied and  infiltrated,  become  gangrenous  at  first  at  the  part 
where  it  is  exposed  to  pressure,  opposite  the  horizontal  part  of 
the  jaw  and  the  dental  arch.  It  appears,  then,  that  gangrene  is 
the  effect  of  oedematous  tumefaction,  the  cause  of  which  we  will 
now  endeavor  to  ascertain. 

It  is  well  known  with  what  facility  the  cellular  tissue  of  new- 
born children  is  infiltrated,  until  so  great  a  tumefaction  is  pro- 
duced as  to  have  induced  several  authors  to  call  the  oedema  by 
the  name  of  induration  of  the  cellular  tissue.  This  disposition 
to  serous  infiltrations,  at  the  same  time  exposes  them  to  indolent 
engorgements  and  to  gangrenous  phlegmasiee  of  the  skin  and 
extremities.  The  frequent  occurrence  of  gangrene  in  the  fin- 
gers, toes,  and  vulva  of  very  young  infants,  has  already  been  al- 
luded to  when  treating  of  the  diseases  of  the  skin.  Now,  does 
not  this  species  of  alteration  coincide  in  the  frequency  of  its  oc- 
currence with  the  predisposition  of  infants  to  oedema  ? — a  predis- 
position which,  without  doubt,  arises  from  the  actual  state  of  the 
circulatory  apparatus,  the  exercise  of  which  is  not  as  yet  perfect- 
ly regulated  ;  and  probably  also  from  the  superabundance  of  se- 
rum in  the  blood  of  young  infants.  This  would  appear  to  be 
the  cause  of  cexlema,  which,  in  its  turn,  becomes  the  predisposing 
cause  of  gangrene. 

If  we  will  now  consider  the  development  of  gangrene  of  the 
mouth  in  children  more  advanced  in  age  than  those  whose  cases 


ON   THE    DISEASES   OF   INFANTS.  191 

have  been  detailed  above,  we  shall  see  that  this  disease  shows  it- 
self principally  in  such  children  as  experience  a  general  infiltra- 
tion which  so  frequently  follows  cutaneous  phlegmasiae,  as  vario- 
la or  rubeola.  They  are  then  in  a  morbid  condition  analogous 
to  the  usual  state  of  new-born  infants  during  the  first  months  of 
life.  Among  the  children  that  are  the  subject  of  M.  Baron's  es- 
say, several  had  had  rubeola  and  were  affected  with  gangrene  of 
the  mouth,  at  the  same  time  that  the  face  and  limbs  were  (Ede- 
matous.* 

It  is  not  without  a  proper  motive  that  I  have  entered  into  these 
considerations  on  the  causes  and  nature  of  the  diseases  of  which 
v/e  are  now  treating,  for  these  data  may  enhghten  us  in  the 
choice  of  the  proper  treatment. 

Treatment. — The  treatment  should  vary  according  to  the  pe- 
riods of  the  disease  ;  when  there  exists  a  general  infiltration,  it 
will  be  necessary  to  meet  it  by  the  means  pointed  out  in  the 
chapter  on  oedema,  or  induration  of  the  cellular  tissue ;  if  this  in- 
filtration should  become  local,  if  the  face,  for  example,  should 
continue  solely  to  be  its  seat,  the  removal  ought  to  be  attempted  by 
aromatic  or  dry  frictions.  If  the  oedema  become  circumscribed, 
if  it  exhibit  a  nucleus  of  engorgement  harder  than  the  other 
parts,  more  energetic  measures  must  be  adopted,  particularly 
frictions  with  ammoniacal  liniment :  the  cheek  should  be  covered 
with  compresses  saturated  with  a  weak  solution  of  hydrochlorate 
of  ammonia.  I  believe  it  will  be  imprudent  to  make  use  of  mer- 
curial frictions  on  account  of  the  liability  of  the  buccal  mem- 
brane to  ulceration  from  its  use,  and  it  is  well  known  that  when 
this  membrane  is  once  ulcerated,  gangrene  makes  extraordinary 
and  rapid  progress. 

Lastly,  if  at  the  interior  of  the  mouth  a  slight  erosion,  and  on 
the  exterior  a  violet  ecchymosis,  should  appear,  it  will  then  be 
necessary  to  resort  to  extreme  measures,  and  cauterize  the  cen- 
tral part  of  the  tumefaction,  either  with  the  butter  of  antimony 
introduced  to  the  bottom  of  a  crucial  incision  made  on  the  out- 

*  A  similar  affection  may  also  be  developed  in  the  genitals.  They  have  been  ob- 
served under  circumstances  analogous  to  those  which  appear  to  influence  the  com- 
mencement and  progress  of  gangrene  of  the  mouth.  We  will  be  contented  to  point 
out  at  present  Ihe  coincidence.  In  the  article  on  the  diseases  of  the  generative  organs, 
we  will  cite  in  its  support  a  remarkable  example  of  gangrene  of  the  vulva. 


192  ON    THE    DISEASES    OF    INFANTS. 

side  of  the  cheeks,  or,  what  is  still  better,  with  the  actual  cautery. 
This  latter  method  of  cauterization  appears  to  M.  Baron  prefera- 
ble to  potential  cautery,  and  he  insists  on  its  employment  as  the 
sole  means  of  restoring  the  health  of  the  patient ;  it  will  be  ne- 
cessary to  have  recourse  to  it  as  soon  as  possible,  for  if  we  await 
the  progress  of  the  disease  before  deciding  on  its  employment,  it 
will  be  necessary  to  destroy  a  great  part  of  the  cheek,  and  thus 
expose  the  child  to  the  certainty  of  having  a  much  larger  cica- 
trix. The  mouth  should,  at  the  same  time,  be  washed  with  ho- 
ney-water, or  acidulated  barley-water. 

When  the  eschar  is  detached,  or  when  it  has  been  destroyed 
by  caustic,  it  is  well  to  have  recourse  to  emollient  cataplasms  and 
lotions,  in  order  to  moderate  the  inflammation. 

As  to  general  treatment,  I  attach  less  importance  to  it,  because 
the  slowness  and  uncertainty  of  its  action  will  never  compensate 
for  the  advantages  of  caustic  applied  directly  to  the  seat  of  a  dis- 
ease the  progress  of  which  is  of  so  frightful  a  nature.  The 
strength  of  the  child  should  at  all  times  be  sustained  with  a  mix- 
ture of  equal  parts  of  milk  and  broth,  or  by  giving  a  few  spoons- 
ful of  Malaga  wine  in  the  course  of  the  day.  Internal  stimulants 
should  be  employed  with  caution,  and  the  practitioner  must  not 
lose  sight  of  the  fact  that,  in  spite  of  the  apparent  feebleness  of 
the  subject,  the  digestive  tube  is  sometimes  the  seat  of  an  irrita- 
tion and  inflammation,  which  may  be  much  exasperated  by  the 
use  of  stimulants.  Yet,  if  the  abdomen  be  without  pain,  if  there 
be  constipation,  it  would  be  well  to  try  the  effect  of  calomel,  or  of 
injections  composed  of  a  solution  of  sulphate  of  soda  and  olive 
oil,  or  castor  oil.  As  the  object  is  to  augment  the  intestinal  secre- 
tion, and  to  establish  a  revulsion  on  a  part  of  the  digestive  passa- 
ges opposite  to  that  occupied  by  the  disease,  calomel  and  sul- 
phate of  soda  ought  to  be  preferred  ;  the  former  taken  by  the 
mouth  in  syrup,  the  latter  given  in  injections.* 

§  IV.  Diseases  of  the  parts  contained  in  the  mouth. 

Glossitis. — Glossitis  is  an  inflammation  of  the  fleshy  part  of 
the  tongue.  I  have  not  observed  this  disease  in  infants  at  the 
breast.    I  have  already  spoken  of  ecchymoses,  which  may  often 

*  See  Appendix,  page  570. 


ON   THE    DISEASES    OP    INFANTS*  193 

be  met  with  at  this  age  in  the  tissue  of  this  organ,  and  which 
must  not  be  confounded  with  the  traces  of  inflammation ;  neither 
should  the  hardness  of  the  tongue,  which  is  seen  almost  always 
in  children  after  death,  be  regarded  as  a  pathological  condi- 
tion ;  this  hardness  is  the  result  of  a  sort  of  cadaveric  rigidity,  or 
a  kind  of  spasmodic  contraction  of  the  muscles  of  the  organ, 
which  occurs  at  the  approach  of  death.  As  to  the  inflammation 
of  the  mucous  membrane  of  the  tongue,  its  history  is  contained 
in  that  of  stomatitis  ;  on  this  account,  I  abstain  from  treating  the 
subject  separately. 


Section  11. 
OP  the  development  and  diseases  of  first   DENTlfiON. 

Art.  1. — Of  the  development  of  the  Teeth. 

In  general,  there  is  great  importance  attached  to  the  pathological 
phenomena  connected  with  the  development  of  the  first  dentition. 
It  has  been  customary  to  attribute  them  to  the  eflbrt  that  nature  ap- 
pears to  make  for  the  protrusion  of  the  teeth  :  it  is  in  the  state  of 
the  gums,  in  the  inflammatory  action  which  takes  place  there,  in 
the  pruritis,  congestion,  and  pain,  that  the  causes  of  the  various  af- 
fections to  which  a  child  is  liable  at  this  age  are  sought.  I  believe 
that  this  manner  of  viewing  the  subject  is  too  exclusive,  and  that  it 
is  wrong  to  admit  these  causes  in  so  general  a  manner :  and  I  pro- 
pose to  show  that  there  is  another  reason  for  all  these  symptoms, 
which  it  is  necessary  to  consider,  in  order  to  treat  methodically 
and  successfully  young  infants  that  are  affected  with  symptoms 
usually  attributed  to  slow,  painful,  and  difllcult  dentition. 

In  order  to  demonstrate  the  views  I  entertain,  it  is  necessary  to 
examine  what  takes  place  anatomically  and  physiologically  in 
the  development  of  the  germ  of  the  teeth,  and  of  the  teeth  them- 
selves, from  their  first  appearance  until  their  protrusion  through 
the  gums ;  considering  afterwards  the  pathological  phenomena 
of  dentition. 

There  exists  between  the  development  of  the  dental  follicles, 
and  that  of  the  maxillary  bone,  some  very  remarkable  relations. 

In  the  embryo  of  about  three  months,  the  alveolary  borders  of 

the  two  maxillary  bones  consist  in  a  uniform  groove,  narrower 

25 


194  ON   THE   DISEASES   OP   INFANTS. 

towards  the  median  line  than  towards  the  molar  portion,  enclos- 
ing a  nnmber  of  follicles  which,  without  being  joined  together, 
are  yet  grouped  so  closely  that  they  appear  to  form  one  many- 
lobed  mass.     From  four  to  five  months  these  lobuli,  which  are 
the  dental  folhcles,  are  more  distinct,  and  in  place  of  being  group- 
ed together,  they  form  a  Ivind  of  elongated  cluster,  composed  ge- 
nerally of  eight  distinct  follicles ;  they  are  all  contiguous,  and 
may  be  raised  from  the  groove  of  the  maxillary  bone,  and  if  care 
be  taken  in  the  dissection,  the  artery  and  nerve  may  be  raised  at 
the. same  time  with  them.     If  the  common   alveolar  cavity  be 
then  examined,  there  will  be  seen  on  the  two  lateral  parietes, 
small  vertical  projections,  corresponding  to  the  slight  furrows 
which  separate  the  follicles,  the  adhesion  of  which  could  not  be 
called  in  question,  since  they  can  be  raised  together,  and  cannot 
be  separated  without  destroying  their  reciprocal  adhesions.     In 
proportion  as   the  foetus  approaches  the  period  of  birth,  these 
commencements  of  the  alveolar  partitions  become  more  evident ; 
these  projections  meet  together  and  unite,  forming  so  many  seg- 
ments or  transverse  partitions,  the  intermediate  spaces  between 
which  constitute  the  alveoli.     It  has  been  remarked  that  all  the 
dental  follicles  have  a  globular  form  ;  but  from  the  moment  the 
alveoli  are  formed,  they  cease  to  continue  of  that  shape,  the  osse 
ous  plate  cuts  them,  if  we  may  say  so,  into  several  small  separate 
follicles,  which  are  attached  to  the  bottom  of  the  maxillary  groove 
by  a  filament  of  nerve  and  a  branch  of  an  artery  ;  these  follicles 
receive  their  form  and  direction  from  the  cell  in  which  they  are 
enclosed. 

At  birth,  these  are  generally  found  in  the  lower  and  upper  jaw, 
and  particularly  in  the  lower  five  well-marked  partitions ;  the 
first  two  spread  laterally,  and  are  destined  to  receive  the  two  inci- 
sors ;  the  third,  narrower  and  generally  oblique  from  below  upward, 
and  from  behind  forward,  are  squeezed  between  the  first  two  and 
the  fourth  y  it  contains  the  canine  teeth  ;  finally,  the  fourth,  broader 
and  rounder,  is  the  alveolus  of  the  first  molar.  The  partition  of 
this  alveolus  opposite  to  that  which  separates  it  from  the  canine 
tooth,  is  found  at  theperiod  of  whicli  we  are  speaking  in  the  mid- 
dle of  the  space  comprised  between  the  symphasis  of  the  lower 
jaw  and  the  coronoid  process ;  so  that  the  fifth  alveolar  cavity  of 
a  new-born  child  extends  from  this  intermediate  point  beyond 


ON   THE    DISEASES    OP    INFANTS.  195 

this  process — that  is  to  say,  almost  half  the  distance  comprised  be- 
tween the  process  and  the  maxillary  symphasis.  In  the  remain- 
der of  the  dental  groove,  there  is  already  to  be  seen  the  rudiments 
of  a  partition  which  is  to  separate  it  into  two  sections,  for  the  se- 
cond and  third  molar  teeth.  At  the  bottom  of  the  new  alveoli, 
which  are  not  yet  perfectly  formed,  the  dental  artery  and  nerve 
are  to  be  seen  directing  their  course  towards  the  internal  part  of 
the  mouth  and  sending  branches  to  the  dental  germs. 

Our  remarks  as  to  the  formation  of  the  dental  alveoli  will  ap- 
ply particularly  to  the  lower  jaw.  The  same  phenomena  occur 
in  the  upper  jaw,  but  the  dental  groove  being  narrower  and 
shorter,  the  alveoli  form  in  a  manner  more  irregular  and  less  dis- 
tinct, although  in  the  main  the  same  process  takes  place. 

But  let  us  see  what  occurs  in  the  germs  of  the  teeth  during  the 
process  of  the  ossification  of  the  jaws. 

Each  follicle,  we  have  said,  is  isolated  in  its  alveolus  ;  this  fol- 
licle, the  structure  of  which  it  is  somewhat  difficult  to  see,  ex- 
hibits more  evidently  at  this  time  the  elements  of  its  composition. 

When  the  groove  was  single  it  was  lined  with  an  extremely 
thin  membrane,  which  was  at  the  time  joined  to  the  follicular 
mass.  In  proportion  to  the  formation  of  the  alveolar  sections 
this  membrane  is  divided,  and  forms,  in  remaining  united  with 
the  internal  surface  of  the  alveoli,  what  is  denominated  alveolar 
periosteum. 

The  follicle  is  composed  of  two  membranes,  difficult  to  see,  it 
is  true,  but  described  by  J.  Hunter,  Fox,  Black,  Bichat,  and 
Meckel.  Between  these  two  membranes,  says  Meckel,  is  found  a 
fluid  more  or  less  abundant  in  proportion  to  the  age  of  the  fostus. 
Meckel  has  well  described  these  two  membranes,  and  I  have  been 
able  to  establish,  with  the  greatest  facility,  on  the  dead  body,  the 
description  he  has  given.  "  The  external  layer  is  m^re  spongy, 
looser,  thicker,  and  softer  than  the  internal.  It  is  very  distinctly 
continuous  with  the  gum  ;  whence  it  is  easy,  in  the  foetus,  espe- 
cially during  the  early  months  of  pregnancy,  to  extract  the  alveoli 
attached  to  the  gum. 

"  The  internal  layer  is  harder,  but  thinner,  than  the  external. 
We  can  demonstrate  that  it  forms  a  sac  entirely  distinct  from  the 
external  and  from  the  gum.  Its  relations  with  the  teeth  are  more 
intimate  than  those  of  the  external  layer,  for  it  is  the  proper  or- 


196  ON   THE    DISEASES    OF    INFANTS. 

gan  of  formation.  The  vessels  of  the  teeth  are  distributed  there 
much  more  evidently,  and  when  injections  succeed,  it  appears 
entirely  red."* 

This  double  sac  encloses  at  first  nothing  more  than  a  red  or 
yellow  fluid,  but  by  degrees  there  is  formed  in  the  centre  a  point 
of  much  greater  consistency,  which,  it  is  said,  is  itself  enveloped 
in  a  thin  membrane,  and  which  constitutes  the  germ  of  the  tooth. 
In  proportion  as  the  follicles  become  more  developed,  and  the  al' 
veolus  begins  to  enclose  it,  the  germ  is  more  distinct ;  and,  ac- 
commodating itself  to  the  cell  which  contains  it,  begins  to  take 
the  shape  of  the  tooth  by  which  it  is  to  be  succeeded.  Lastly, 
about  the  end  of  five  months,  at  the  superior  part  of  the  germ  of 
the  incisor  teeth,  there  appear  two  or  three  small  red  indurated 
points,  almost  always  situated  at  the  side.  These  small  points 
soon  unite,  thus  forming  a  species  of  bifurcation,  of  which  the 
incisors  sometimes  exhibit  a  trace  on  their  protrusion.  After- 
wards a  similar  point  appears  at  the  summit  of  the  follicle  of  the 
canine  teeth,  and  several  others  on  those  of  the  first  molar. 

Small  scales  quickly  succeed  these  primitive  indurations,  soli- 
tary in  the  incisors  and  canine  teeth,  multiple  and  distinct  in  the 
first  molar.  These  scales  already  present  an  osseous  consistence  ; 
they  gradually  enclose  the  pulp,  to  which  they  are  solidly  adhe- 
rent, as  they  increase  in  size.  It  is  evident  that  they  are  the  pro- 
duct of  a  kind  of  secretion  taking  place  on  the  surface  of  the  den- 
tal germ.  This  ossification  soon  makes  progress  from  above 
downward;  and  when  it  has  taken  the  form  of  the  crown  of  the 
tooth,  it  then  exhibits  a  depression  or  circular  neck,  below  which 
it  elongates  in  the  form  of  a  root. 

Hitherto,  we  have  seen  that  it  was  at  the  external  surface  of  the 
germ  that  the  ossification  commenced,  proceeding  from  within 
outwards,  so  that  the  little  osseous  crown  encloses  in  its  cavity 
the  pulp  or  germ,  and  is  enveloped  by  the  double  membrane 
which  formed  the  walls  of  the  dental  follicle.  The  internal  layer 
of  this  double  membrane,  applied  directly  to  the  point  of  ossifica- 
tion, secretes,  according  to  the  greater  number  of  anatomists,  the 
enamel  of  the  teeth. 

♦  J.  F,  Meckel,  Alanuel  d'anat.  general,  descript.  et  pathol.  traduit  par  A.  Gourdan 
ct  G.  Breschet.  Paris,  18^.— [V.  English  translation  by  A.  Sidney  Doane,  M.  D,, 
V.  3,  p.  231.— S.] 


ON  THE  DISEASES  OP   INFANTS.  197 

Thus  the  phenomena  of  the  ossification  of  the  jaws,  and  those 
of  ttie  development  of  the  teeth,  are  simultaneously  affected  dur- 
ing the  continuance  of  the  foetus  in  the  uterus.  From  this  pe- 
riod, the  disposition,  form,  and  progress  of  the  teeth,  appear  to  be 
governed  by  the  development  of  the  maxillary  bones,  and  the 
changes  which  occur  in  the  dental  groove.  This  assertion  is 
supported  by  the  well-known  fact  that  the  alveoli  are  much 
sooner  formed  in  a  distinct  manner  in  the  lower  than  in  the  upper 
jaw ;  and  it  is  in  the  lower  jaw  that  the  teeth  are  developed  first, 
and  appear  sooner  on  the  outside  of  the  gums  at  the  time  of  den- 
tition. 

Until  this  time,  the  teeth  did  not  require  to  be  separated  from 
each  other,  and  to  have,  as  we  may  say,  a  separate  existence ;  but 
the  development  of  the  alveoli  has  placed  them  in  a  suitable  con- 
dition for  such  a  change.  We  shall  now  see  by  what  mechanism 
they  shoot  up  from  the  jaws,  pierce  the  gums,  and  protrude  into 
the  mouth. 

There  have  been  two  different  opinions  presented  on  the  sub- 
ject of  dentition.  M.  Serres  has  advanced  the  idea  of  the  exist- 
ence of  some  force  exterior  to  the  tooth — a  species  of  gubernacu- 
lum— drawing  and  conducting  it  to  the  outside  of  the  gums.* 
Other  authors  have  found  the  cause  existing  only  in  the  evolu- 
tion of  the  tooth.  For  my  part,  I  have  not  seen  the  gubernacu- 
lum  spoken  of  by  M.  Serres,  and  am  persuaded  that  this  protru- 
sion of  the  teeth  depends  both  on  their  evolution  and  the  con- 
comitant development  of  the  maxillary  bones  ;  it  is  then  a  phe- 
nomenon almost  of  a  mechanical  nature,  which  h£is  been  vainly 
sought  to  be  explained  by  brilliant  theories,  but  which  simple 
anatomical  observations  have  enabled  us  to  demonstrate. 

Indeed,  at  the  period  of  birth,  the  dental  germs  exhibit  points 
of  ossification  which,  with  the  exception  of  the  canine  teeth,  are 
all  situated  on  the  same  line,  and  do  not  pass  the  osseous  border 
of  the  dental  groove  ;  the  inferior  extremity  of  the  germ  is  not  as 
yet  ossified ;  it  remains  at  this  part  soft  and  transparent,  and  the 
osseous  cap  appears  to  be  held  at  the  upper  part  of  the  groove  by 
its  adhesion  to  the  alveolar  periosteum  which  lines  the  inferior 
border  of  the  gum.     The  gum  is  of  a  firm  tissue,  solid  and  dry 

*  Mem.  sur  la  dentition,  inserted  in  the  Mem.  de  la  Soc.  Med,  d'emul,  t,  8. 


198  ON  THE  DISEASES  OP  INFANTS. 

enough  to  have  been  compared  to  cartilage,  and  at  the  place  des 
tined  to  be  supplied  with  the  teeth  is  sufficiently  solid  to  fulfil, 
provisionally,  their  functions.  Sometimes  this  border  presents 
projections  arid  depressions  analogous  to  the  teeth  and  the  de- 
pressions which  separate  them.  I  have  seen  in  a  young  infant 
these  projections  so  evident,  and  possessing  so  distinctl^r  the 
shape  of  the  incisors  and  molar  teeth,  that  it  was  said  the  child 
had  fleshy  teeth. 

The  tissue  of  the  gums  after  birth  gradually  loses  its  consis- 
tence ;  it  becomes  soft,  and  insensibly  spreads  in  such  a  manner 
as  to  exhibit,  in  place  of  a  continued  border,  a  slightly  depressed 
surface,  which  does  not  swell  except  when  affected  by  inflamma- 
tion. The  opening  in  it  for  the  passage  of  the  teeth  cannot  be 
distinguished. 

When  the  cervix  of  the  tooth  has  acquired  a  determinate  form, 
the  root  grows  larger  and  reaches  the  bottom  of  the  alveolus. 
The  maxillary  bone  also  making  progress  in  its  ossification, 
rises,  as  it  were,  to  the  root  of  the  tooth,  and  soon  there  is  noth- 
ing, to  be  seen  between  the  tooth  and  the  bottom  of  the  cell,  ex- 
cept a  small  space  occupied  by  the  pulp,  and  in  part  lodged  in 
the  dental  cavity.  The  two  alveoli  of  the  incisor  teeth  are  found 
to  be  on  the  same  plane,  when  they  are  examined  sometime  after 
birth.  At  four  months  this  diflference  is  still  more  evident ;  the 
inferior  maxillary  bone  at  the  median  line  grows  rapidly  in 
height  and  thickness,  and  appears  to  raise  with  it  the  first  incisor, 
which,  gradually  entering  in  the  gum,  insensibly  separates  it, 
and  in  which  it  becomes  imbedded.  Finally,  about  the  seventh, 
eighth,  and  ninth  month,  the  first  two  lower  incisors  appear  out- 
side of  the  gum.  The  second  incisor  tooth  shows  itself  much 
later,  because  the  bottom  of  it^  alveolus  being  lower  by  a  line,  or 
half  a  line,  than  the  upper,  in  order  to  reach  its  level,  has  to  pass 
over  a  much  greater  space.  I  have  now  before  me  the  lower 
jaws  of  four  infants  that  have  died  at  the  usual  time  of  the  ap- 
pearance of  the  first  incisors ;  in  neither  had  the  second  appear- 
ed. On  measuring  the  length  of  the  four  incisor  teeth  they  were 
all  nearly  the  same,  having  the  same  degree  of  ossification  ;  but 
the  first  appeared  soonest,  because  the  ossification  of  the  jaw  had 
produced  an  earlier  elevation  of  the  alveolus,  so  that. there  exist- 
ed between,  them  a  difference  of  almost  a  line  at  the  level  of  their 


ON    THE    DISEASES    OP    INFANTS.  199 

insertion :  to  make  a  comparison,  the  bottom  of  these  two  alveoli 
presented  the  same  difference  as  two  consecutive  steps  of  a  stairs. 

The  canine  teeth  do  not  appear  immediately  after^  because 
they  are  much  more  deeply  implanted,  are  confined,  and  situated 
obliquely  in  their  narrow  alveoli,  and  require  some  enlargement 
of  the  dental  arch,  and  ossification  of  the  maxillary  bone,  in  order 
.0  obtain  at  the  bottom  of  their  cells  a  point  of  support  necessary 
for  their  progress  upward.  But  the  first  molars,  the  ossification 
of  which  has  commenced  early,  and  which  are  generally  more 
superficial  than  the  canine  teeth,  appear  much  sooner  than  they ; 
following  the  second  incisor.  Lastly,  the  canine  tooth  comes  in 
its  turn,  completing  the  number  of  teeth  which  furnish  the  jaw 
during  the  first  year  of  an  infant's  life.  Dentition  usually  com- 
mences from  the  seventh  month  to  a  year  ;  this,  however,  varies 
much. 

From  these  considerations,  which  are  based  upon  the  rigor- 
ous observation  of  facts,  it  results — -Ist,  That  the  teeth  are  the 
product  of  secretion  ;  2dly,  That  their  development  regularly  fol- 
lows the  progress  of  the  ossification  of  the  maxillary  bones ; 
3dly,  That  their  appearance  outside  of  the  gum  results  in  part  from 
the  evolution  of  the  teeth,  and  in  part  from  the  development  of 
the  ossification  and  enlargement  of  the  alveoli  and  dental  arch  ; 
4thly,  That  the  cause  of  the  successive  appearance  of  the  first  and 
of  the  second  incisor,  then  of  the  first  molar,  and  afterwards  of 
the  canine  tooth,  is  altogether  mechanical  ;  that  it  resides  in  the 
more  or  less  prompt  formation  of  the  alveoli  proper  to  each  of 
these  teeth,  and  in  the  greater  or  less  depth  of  their  implantation 
in  the  maxillary  bone. 

From  this  view  of  the  subject,  it  is  not  necessary  to  admit  as 
a  cause  the  guhernaculum  dentium  of  M.  Serres.  This  ana- 
tomist, moreover,  considers  it  difficult  to  establish  its  e'xistence  in 
reference  to  the  first  teeth,  but  that  it  is  easily  discovered  in  the 
second  dentition.  It  is  not  my  business  to  consider  the  pheno- 
mena of  the  second  dentition,  but  to  confine  myself  to  the  appear- 
ance of  the  first  teeth.  I  will,  however,  make  one  remark  ;  it, is 
this — that  the  teeth  of  second  dentition  are  less  regularly  ranged 
than  those  of  the  first.  If,  therefore,  the  guhernaculum  dentium 
be  not  chimerical,  it  is  at  least  very  useless,  since  the  teeth  are 
ranged  with  less  regularity  at  a  period  when  it  is  more  easy  to 


200  ON  THE   DISEASES  OF   INFANTS. 

recognise  the  apparatus  which  directs  them,  than  when  the  appa- 
ratias  is  so  small  that  it  cannot  be  seen. 

As  to  the  follicles  which  are  situated  in  the  thickness  of  the 
gums,  and  which  M.  Serres  considers  as  destined  to  lubricate 
the  parts  through  which  the  teeth  pass,  Meckel  regards  them  as 
new  formations  produced  by  the  irritation  caused  by  the  teeth, 
and  in  no  respect  differing  in  their  nature  from  that  of  abscesses.* 
These  follicles,  which  consist  only  of  a  yellow  fluid,  sometimes 
thickened,  appear  to  me  to  be  formed  in  the  following  manner : 
during  the  time  the  tooth  is  undergoing  development,  it  presses 
on  all  sides  the  fluid  and  soft  parts  which  the  alveolus  encloses ; 
the  fluid,  which  is  still  at  the  root  of  the  tooth,  and  which  is  but 
the  remainder  of  that  which  the  dental  sac  contained  before 
ossification,  is  crowded  back,  and  lodges  either  at  the  lateral  part 
or  at  the  summit  of  the  teeth.  In  the  molar  teeth,  the  crowns  of 
which  exhibit  elevations  and  depressions,  this  fluid  ordinarily 
lodges  in  these  depressions  in  the  form  of  small  semi-fluid  drops, 
irregularly  round.  When  the  gums  are  torn  in  the  dead  body  of 
a  child  of  the  age  of  nine  months,  or  a  year,  there  is  often  found 
the  small  yellow  bodies  pointed  out  by  M.  Serres,  and  there  is 
frequently  discharged  from  the  lateral  parts  of  the  alveolus  a 
small  quantity  of  viscous  fluid,  which  appears  to  have  escaped 
by  the  rupture  which  was  made  in  e  sac  containing  the  germ 
of  the  tooth  ;  so  that  it  is  altogether  probable  that  the  small  col- 
lection of  follicular  appearances  spoken  of  by  M.  Serres  are  nei- 
ther follicles  nor  abscesses,  but  are  the  result  of  an  effusion  ol 
superaDundant  fluid  contained  in  the  membranes  of  the  germ. 
This  effused  fluid  may  also  lubricate  the  soft  parts  which  sur- 
round the  tooth,  and  perform  to  a  certain  extent  the  functions 
attributed  by  M.  Serres  to  these  pretended  follicles. 

It  is  by  considering  the  development  of  the  teeth  as  I  have 
done,  in  their  relation  to  the  progress  of  ossification  of  the  jaws, 
and  of  the  formation  of  the  aveoli,  that  we  are  able  to  explain 
without  hypothesis  and  without  recourse  to  theories  more  bril- 
liant than  true,  all  the  phenomena  belonging  to  the  appearance 
of  the  teeth.  By  studying  dentition,  therefore,  in  this  point  ot 
view,  M.  Leveille,  in  one  of  the  best  works  which  I  think  has 

*  Loc,  cit.  t.  3,  p,  347. 


ON    THE    DISEASES    OP    INFANTS.  201 

been  published  on  this  subject,  has  explained  with  great  clearness 
all  the  circumstances  of  this  physiological  phenomenon.*  M* 
Delebarre  has  also  made  an  approximation  to  the  truth,  in 
attaching  the  greatest  importance  to  the  relation  between  the 
development  of  the  teeth  and  those  of  the  jaws.f 

Art.  2. — Anomalies  of  Dentition. 

If  all  that  authors  had  written  on  the  aberration  of  the  procesi?! 
of  dentition  should  be  recorded  here,  an  extended  chapter  of 
absurdities  would  be  the  result,  and  on  this  account  I  shall 
merely  point  out  the  opinions  which  appear  to  be  the  nearest  to 
the  truth,  and  which  anatomy  and  physiology  alone  can  properly 
elucidate.  The  general  anatomy  of  Meckel  contains  very  im^ 
portant  details  on  this  subject. 

The  teeth  present  anomalies  in  their  development  ;  that  is  to 
say,  they  may  appear  earlier  or  later  than  the  period  of  first  den- 
tition, which  is  usually  from  the  tenth  month  to  one  year.  This, 
however,  is  of  little  importance  ;  neither  should  there  be  attached 
any  to  the  irregularity  with  which  they  proceed  from  the  gums. 
Sometimes  children  are  seen  born  with  teeth  ;  they  are  generally 
the  incisors.  This  anomaly  often  coexists  with  a  malformation 
of  the  face,  and  particularly  with  hare-lip  and  congenital  division 
of  the  velum.  It  is  also  possible  for  the  mouth  not  to  exhibit  the 
least  anomaly,  although  furnished  early  with  teeth.  Such  in- 
stances are  found  in  the  case  of  Louis  XIV.  and  that  of  Mi- 
rabeau. 

These  teeth  are  generally  of  but  short  duration,  because,  being 
but  superficially  implanted,  they  become  still  less  so  in  propor- 
tion to  the  development  of  the  maxillary  bone,  and  are  on  this 
account  quickly  shed  ;  at  least,  this  is  what  I  saw  in  a  child 
brought  in  the  month  of  June  to  the  Hospice  des  Enfans 
Trouves.  It  had  two  teeth,  one  of  which  was  shed  at  the  end  of 
six  weeks,  and  the  other  very  soon  followed. 


*  Mem.  sur  Us  rapports  qui  existent  entre  les premiers  et  tes  secondes  dents,'  eidt 
Mem.  de  la  Societe  med.  d'emulation,  t.  7  and  9. 

t  Methode  Naturelle  de  diriger  la  seconde  dentition.  Paris,  1826.  See  also  thd 
Memoir  ot  Miel,  entitled,  Quelque  idees  sur  le  rapport  des  deux  dentitions,  et  suf 
Vaccroisement  des  machoires  dans  Vhomme.     Mem.  de  la  Soc.  med.  d'emulation,  t.  7. 

26 


202  ON   THE    DISEASES   OF   INFANTS. 

If  these  teeth  interfere  with  sucking,  they  should  be  removed; 
for  it  would  be  better  for  the  child  to  be  without  incisor  teeth 
until  the  period  of  second  dentition,  than  to  be  deprived  of  the 
means  of  nourishment,  without  which  its  life  would  be  en- 
dangered. 

With  reference  to  number,  the  teeth  may  present  any  anoma- 
lies at  the  time  of  first  dentition  ;  and  it  is  not  until  the  appear- 
ance of  the  second  set  that  it  is  possible  to  find  two  rows  in  the 
same  individual,  as  this  results  from  the  continuance  of  those  teeth 
which,  in  their  natural  state,  are  but  temporary.  The  anomalies 
of  direction  and  of  situation  are  of  more  frequent  occurrence  ;  even 
in  children  in  the  cradle,  they  are  always  the  result  of  malforma- 
tion in  the  superior  or  inferior  alveolar  arch.  It  may  easily  be 
conceived,  that  if  the  alveolus,  the  shape  of  which  generally  di- 
rects the  growth  of  the  tooth,  be  not  readily  formed  in  conse- 
quence of  the  narrowness  of  the  maxillary  bone,  the  tooth  itself 
will  also  partake  of  the  same  deviation,  protruding  outside  of  the 
line  of  the  other  teeth,  or  at  some  distance  from  the  dental  arch. 
Albinus  has  recorded  the  case  of  an  individual  in  whom  there 
were  two  teeth  of  considerable  length  and  thickness,  that  were 
hidden  in  the  nasal  process  of  the  maxillary  bone  ;  their  bodies 
were  above,  and  the  roots  below.*  "When  the  primitive  situation 
of  the  germ  of  the  teeth  is  considered,  we  ought  not  to  be  sur- 
prised at  the  strangeness  of  their  position,  for  they  neither  had 
the  dental  groove  nor  the  alveoli  to  direct  them  in  their  develop- 
ment and  progression.  He  also  met  with  a  tooth  in  the  part  of 
the  maxillary  bone  which  unites  with  the  palate  ;  and  Sabatier 
once  saw  an  individual  who  had  two  canine  teeth  in  the  same 
situation.  It  is  worthy  of  remark,  that  almost  all  teeth  that  are 
thus  separated  from  their  natural  position,  are  of  this  kind.  Now, 
in  the  development  of  the  germ  of  the  teeth  the  canine  are  those 
which  are  the  last  to  form ;  besides,  they  are  often  compressed  be- 
tween the  other  teeth.  If  the  dental  arch  be  not  sufllciently  spread 
to  allow  of  a  consistent  place  for  the  growth  of  the  tooth,  it  may 
be  easily  understood  how  it  can  be  pushed  backwards  and  grow 
opposite  to  the  place  assigned  to  it  by  nature. 

I  do  not  know  of  any  well  authenticated  cases  of  molar  teeth 

*  Sabatier,   Traite  complet  d'anat.     Paris  in  — 12,  3  v.  t.  p.  80. 


ON  THE    DISEASES    OP    INFANTS.  203 

being  formed  in  the  place  of  incisors.  I  am  unable  to  conceive 
how  this  aberration  can  occur,  because  the  alveolus  of  the  incisor 
tooth  is  too  narrow  to  enclose  a  germ  of  the  form  proper  to  the 
molar  tooth ;  in  every  instance  this  tooth  occupying  an  ununited 
alveolus,  has  a  singular  form,  and  is  nothing  more  than  an  abor- 
tive molar. 

Teeth  may  be  wanting  either  in  whole  or  in  part.  The  for- 
mer case  is  extremely  rare  ;  yet  it  appears  to  have  been  observed, 
since  Borelli  has  given  the  case  of  a  woman  aged  sixty  years.  If 
the  primitive  teeth  are  not  developed,  the  permanent  may  appear 
much  later  than  the  usual  time  for  their  protrusion.  Certain 
diseases  of  the  gum  and  germ,  which  subject  will  be  considered 
hereafter,  may  destroy  the  germ  of  the  teeth,  and  thus  cause  their 
absence  in  certain  individuals.* 

If  the  alveolar  partitions,  during  the  development  of  the  jaws, 
be  arrested  in  their  formation,  and  if  the  dental  groove  remain 
free  in  all  its  extent,  the  dental  germs  are  then  always  grouped 
and  adherent;  the  teeth  which  succeed  them,  are  themselves 
united  and  form  a  unique  mass,  composed  of  several  teeth  adher- 
ing either  at  their  crowns  or  roots.  Sosmmering,  says  Marjolin, 
has  seen  an  example  of  this  disposition  of  teeth,  which,  however, 
must  not  be  confounded  with  the  union  of  the  teeth  by  a  collec- 
tion of  tartar.t  Fox  has  likewise  given  cases  of  the  mutual  ad- 
hesion of  adjacent  teeth  by  their  bodies  or  roots. 

I  shall  here  conclude  my  remarks  on  the  anomalies  of  the 
teeth,  which  are  indeed  but  very  rarely  met  with  in  children  at 
the  breast. 

Art.  3. — Diseases  of  Dentition. 

M.  Guersent,  in  the  article  on  Dentition  in  the  Dictionaire  de 
Medicine,  commences  with  an  observation  full  of  truth,  and 
which  comes  in  support  of  the  opinion  advanced  above.  "  Most 
of  the  diseases  of  infancy,"  says  this  excellent  pathologist,  "  have 
been  attributed  to  teething.  The  difficulty  of  an  accurate  obser- 
vation of  diseases  at  this  early  age,  and  the  little  positive  know- 
ledge we  possess  in  this  department  of  pathology,  have  contribu- 

*  See  Appendix  page  570. 
Marjolin,  art.  Dent,  path,  du  Diet,  de  Msd.  en  21  vol. 


204  ON   THE    DISEASES    OF    INFANTS. 

ted  greatly  to  the  establishment  of  this  opinion ;  and  this  preju- 
dice, the  result  of  our  ignorance,  has  at  last  become  popular,  like 
all  the  other  prejudices  in  medicine."* 

As  I  propose,  in  this  work,  to  elucidate,  as  far  as  I  can,  the 
diseases  of  infancy,  I  shall  not  treat  here  of  the  sympathetic  af- 
fections of  dentition,  such  as  fever,  convulsions,  vomiting,  diar- 
rhoea, etc.  I  shall  consider  these  symptoms  in  treating  of  the  his- 
tory of  the  various  organs,  or  the  systems  of  the  organs,  of  young 
infants,  and  I  shall  then  endeavor  to  demonstrate  how  these  dis- 
eases become  so  common  at  the  period  of  the  protrusion  of  the 
teeth,  and  likewise  that  they  are  not  the  cause  of  this  frequency. 
I  shall  also  make  it  appear  why  convulsions  of  children  at  the 
breast,  which,  since  the  days  of  Hippocrates  to  the  present  time, 
have  been  attributed  to  the  irritation  of  the  teeth,  do  not  depend 
directly  on  this  irritation,  but  are  really  owing  to  other  causes. 
I  shall  then  consider  the  local  symptoms  of  dentition. 

Dentition  being  a  natural  function,  may  occur  without  giving 
rise  to  the  least  untoward  accident,  and,  with  the  exception  of  an 
increase  of  saliva,  many  children  pass  this  period  without  any 
disturbance  of  their  health. 

Yet  there  almost  always  occurs  some  itching  of  the  gums, 
•\vhich  often  become  a  little  red  and  slightly  tumefied.  This  tu- 
mefaction is  generally  transient,  and  the  accompanying  irritation 
often  imaginary,  for  nurses  suppose  that  it  exists  because,  in  pla- 
cing their  fingers  in  the  child's  mouth,  it  bites  with  evident  gra- 
tification, thus  calming  the  irritation  of  the  gums.  But  this  con- 
clusion must  be  false,  for  how  can  we  conceive  that  compression 
of  the  inflamed  gums  on  the  finger  can  ease  the  pain  ?  On  the 
contrary,  the  distress  must  be  thereby  augmented,  and  the  eager- 
ness with  which  infants  bite  whatever  is  put  in  their  mouths, 
is  attributed  to  the  effects  of  a  wish  to  allay  the  itching  of  the 
gums.  Do  we  not  rather  see  in  this  the  commencement  of  the 
proper  motion  of  the  jaw,  which  has  just  acquired  a  new  degree 
of  development,  and  is  soon  to  become  a  part  of  the  digestive  ap- 
paratus ? 

We  have  seen  that  from  the  period  of  birth  to  eight  months  or 
a  year,  the  teeth  grow  and  raise  themselves  from  the  bottom  of 

*  Did,  de  Med,  en  2X  vol.  t.  6, 


ON    THE    DISEASES    OF    INFANTS.  205 

the  alveoli  to  the  surface  of  the  gums.  During  this  time,  an  af- 
riux  of  blood  takes  place  towards  the  gums,  producing  in  them 
and  in  the  jaws  a  state  of  congestion  and  of  inflammation ;  the 
ulterior  progress  of  which  may  soften  the  tissue  of  the  gums, 
give  rise  to  slight  hemorrhages,  excoriations,  and  ulcerations 
more  or  less  deep,  and  often  end  in  the  destruction  of  the  germs 
of  the  teeth. 

These  affections  are  observed  from  the  most  tender  age  to  the 
time  of  the  appearance  of  the  first  teeth.  They  must  not  be  con- 
founded with  gangrene  of  the  mouth,  already  considered ;  but 
they  have  a  nearer  relation  to  scorbutic  affections  of  adults.  I 
will  endeavor,  by  some  examples,  to  convey  an  idea  of  their 
character. 

CASE  XV. — Tumefaction  of  the  gums,  effusion  of  blood  intne 
alveoli, — Marie  Dume,  aged  six  days,  of  a  tolerably  strong  constitu- 
tion, having  a  good  color  in  the  face,  but  exhibiting  a  slight  jaundiced 
tint  on  the  trunk  and  limbs,  entered  the  infirmary  on  the  13th  of  Oc- 
tober. She  cried  a  little,  but  remained  tranquil,  as  if  drowsy  ;  the 
mucous  membrane  of  the  mouth  was  in  a  natural  state,  but  the 
tongue,  at  its  borders  and  extremity,  was  red.  (Gummed  rice-wa- 
ter.) On  the  fifteenth,  the  jaundice  was  less  intense,  and  there  ap- 
peared a  copious  diarrhoea  ;  the  child  became  pale,  and  cried  much  ; 
the  gums  of  the  upper  jaw  were  swelled  without  being  red.  [Same 
treatment.)  The  same  state  continued  until  the  20th  of  October  ;  the 
diarrhoea  then  increased  ;  she  became  pale,  but  without  much  emacia- 
tion ;  the  upper  gum  was  constantly  swelled,  and  of  a  livid  red.  On 
the  twenty-fifth,  all  the  symptoms  increased,  and  the  child  died  in 
the  night. 

Post  mortem  examination. — The  upper  gum  of  the  right  side  ex- 
hibited a  violet-colored  tumefaction,  with  an  evident  fluctuation.  An 
efifusion  of  black  fluid  blood  was  found  in  the  alveoli  of  the  first  three 
teeth.  The  incisor  teeth  and  the  portion  of  the  germ  which  was  not 
ossified,  were  loose  in  the  midst  of  the  efliised  blood  which  formed 
the  tumor ;  the  osseous  crowns  of  the  teeth  were  soft,  red,  and  some- 
what macerated  in  the  fluid.  The  surrounding  soft  parts  had  begun 
to  separate  from  the  alveolar  pocess.  The  rest  of  the  mouth  was 
healthy. 

At  the  lower  extremity  of  the  oesophagus,  there  were  found  some 
traces  of  muguet,  and  traversing  the  surface  of  the  stomach,  several 


206  ON   THE    DISEASES   OP    INFANTS. 

Striae ;  the  mucous  membrane  at  the  end  of  the  duodenum  was  thick 
and  tumefied.  In  the  neighborhood  of  the  ileo-caecal  valve,  were  six 
follicular  spots,  red,  and  much  tumefied  ;  the  liver  was  gorged  with 
blood ;  the  bile  was  abundant,  ropy,  and  of  a  pale  green.  The 
lungs,  heart,  and  brain  were  healthy. 

This  case  is  remarkable  in  two  respects :  it  shows  us,  in  the 
first  place,  that  the  affections  having  their  seat  in  the  teeth  or 
their  germs,  may  exist  at  the  earliest  periods  of  life,  as  at  the 
seventh  and  ninth  month;  and  in  the  second  place,  it  enables 
us  to  understand  how  it  happens  that  hemorrhages  occur  in  the 
dental  grooves  after  this  sanguineous  congestion,  so  frequent  in 
these  parts  in  young  infants. 

The  following  instance  gives  us  a  case  of  the  same  affection  in 
a  more  advanced  stag^e. 

CASE.  XVI. — Muguet,  sanguineous  congestion  and  destruc- 
tion of  the  gums,  suffocating  cough,  gastritis. — Anna  Gens,  aged 
twenty  days,  entered  the  infirmary  on  the  13th  of  August.  She  was 
vigorous,  and  generally  in  good  condition  ;  the  tongue  was  red  on 
the  upper  surface,  where  there  appeared  several  spots  of  muguet ; 
it  was  on  this  account  that  the  nurse  ceased  to  have  the  care  of  her. 
{Gummed  barley-water,  emollient  gargles,  milk  and  water.)  On 
the  fourteenth,  the  muguet  had  extended  over  the  whole  mucous 
membrane  of  the  tongue  even  to  the  velum.  (Same  treatment.)  On 
the  eighteenth,  the  child  vomited  the  drinks  immediately  after  they 
were  taken  ;  nothing  remarkable  occurred  until  the  1st  of  Septem- 
ber, when  the  respiration  became  much  accelerated  ;  the  skin  at  night 
was  very  hot  and  dry ;  the  pulse  was  full,  but  did  not  beat  with  more 
frequency  than  ordinary,  (ninety  pulsations.)  The  mouth  was  co- 
vered with  several  patches  of  muguet.  (Dococt.  of  m,arshmallows, 
a  linctus  with  half  drachm  of  syrup  of  poppies,  strict  diet.)  On 
the  eighth,  the  cough  increased,  and  assumed  the  characters  of  hoop- 
ing cough ;  the  face  was  oedematous ;  the  gums  were  red,  puffed, 
and  bloody.  (Same  treatment.)  On  the  twelfth,  there  was  a  con- 
siderable increase  of  all  the  symptoms,  and  a  general  tumefaction  of 
the  gums  and  jaws.  On  the  fourteenth,  the  upper  gum  of  the  right 
side  was  more  tumefied  than  at  other  points.  On  the  fifteenth,  the 
deglutition  was  more  difficult,  and  the  drinks  regurgitated  through 
the  nose ;  the  child,  by  the  violence  of  the  cough,  was  every  mo- 
ment threatened  with  suffocation.    (Same  treatment.)    On  the  seven- 


ON   THE    DISEASES    OF    INFANTSf.  207 

tecnth,  the  deglutition  of  liquids  was  almost  impossible,  whilst  the 
child  easily  swallowed  pap.  On  the  eighteenth,  the  swelling  of  the 
upper  lip  had  made  considerable  progress  ;  the  face  continued  cede- 
matous  ;  the  muguet  no  longer  appeared,  and  the  buccal  membrane, 
in  general,  was  not  very  red.  On  the  nineteenth,  a  violet-colored 
ecchymosis  manifested  itself  on  the  ala  of  the  nose ;  the  cough  con- 
tinued frequent,  but  without  suffocation  ;  the  skin  was  very  hot,  yet 
the  pulse  was  in  the  natural  state.     The  child  died  at  night. 

The  examination  of  the  body  was  made  on  the  ensuing  day.  An 
cedematous  swelling,  red,  and  very  soft,  was  observed  on  the  upper 
right  gum  ;  there  existed,  on  this  side  only,  an  cedematous  tumefac- 
tion of  the  parietes  of  the  mouth  ;  but  on  the  outside,  the  skin  did  not 
exhibit  the  cupreous  and  oily  aspect  which  characterizes  the  precur- 
sory oedema  of  gangrene  of  the  mouth.  On  opening  the  tumor  of  the 
gums,  it  was  found  to  consist  of  grumous  and  black  blood,  in  the 
midst  of  which  floated  the  germs  of  the  teeth,  entirely  detached,  fall- 
ing out  with  the  blood  which  flowed  from  the  tumor.  There  also 
existed  a  thick  bed  of  muguet  at  the  base  of  the  tongue.  The  sto- 
mach was  contracted  and  wrinkled,  and  its  mucous  coat  thick  and  of 
an  intense  red.  At  the  lower  part  of  the  ileon,  there  were  some 
follicular  patches,  pale,  and  slightly  projecting.  The  liver  was 
gorged  with  blood,  and  the  entire  venous  system  of  the  abdomen 
was  in  a  very  remarkable  state  of  congestion. 

The  glottis  was  the   seat  of  a  strongly  marked  oedema ;  the  tra- 
chea, bronchiae,  and  lungs  were  healthy ;  the  arterial  duct  and  fora 
men  ovale  were  both  closed. 

The  coexistence  of  the  affections  of  the  teeth,  the  congestion 
of  the  gums,  and  the  oedematoiis  swelling  of  the  face  on  the  dis- 
eased side,  ought  particularly  to  be  noted.  This  agreement  es- 
tablishes the  existence  of  some  connection  between  the  diseases 
of  the  gums  and  of  the  teeth,  and  gangrene  of  the  mouth.  I  do 
not  doubt  that  this  latter  disease  may  follow  the  swelling  and  the 
disorganization  of  the  gums.  If  it  should  occur  in  a  child  in 
whom  the  second  dentition  had  commenced,  the  consequences 
would  be  very  serious,  and  might  result  in  the  loss  of  the  teeth 
for  the  remainder  of  life.  I  am  led  to  believe  that  Van  Swieten 
has  alluded  to  this  complication  of  gangrene  of  the  mouth,  when 
he  says  :  Vidi  aliquoties  in  pauperum  infantihus^  qui  omnin6 
neglecti  fuerant  partem  ossis  maxillcB  cecedisse  una  cum  alvo- 


208  ON   THE   DISEASES   OF    INFANTS. 

oils  et  dentihus  contentis :  unde  in  hoc  loco  destructcc  maxillce 
told  vitdfuerunl  adentuli* 

These  effusions  in  the  alveoli  become  less  frequent  in  propor- 
tion as  the  child  advances  in  age,  and  as  the  tooth,  in  becoming 
developed,  fills  the  alveolar  cavity.  The  sanguineous  exhala- 
tion then  occurs  on  the  surface  of  the  gums  in  the  buccal  cavity, 
a  circumstance  which  can  scarcely  be  perceived  because  the 
child,  by  sucking,  prevents  it  from  flowing  to  the  outside.f 

The  gums  of  a  young  child  may  become  much  more  superfi- 
cially inflamed ;  at  the  time  of  the  appearance  of  the  first  teeth 
they  become  partially  tumefied,  and  a  slight  local  inflammation 
ensues  at  the  place  of  each  tooth.  I  have  seen  this  affection  in  a 
child  of  eighteen  months,  in  whom  all  the  first  teeth  had  protrud- 
ed. This  inflammation  was  characterized  by  a  red  festooned 
line  following  the  contour  of  the  gums  in  the  direction  corre- 
sponding with  the  neck  of  the  teeth. 

It  is  possible  that  this  inflammation  may  be  so  far  advanced  as 
to  cause  a  dryness  of  the  mouth,  and  a  general  redness  of  the  mu- 
cous membrane  lining  this  cavity — in  a  word,  all  the  characters 
of  erythematic  stomatitis  accompanied  with  fever,  restlessness, 
and  constant  crying ;  but  it  must  be  admitted  that  this  is  of  rare 
occurrence.  Great  attention  must  be  paid  to  the  treatment  of 
this  phlegmasia,  the  propagation  of  which,  by  contiguity  to  other 
parts  of  the  digestive  passages,  being  very  rapid. 

The  treatment  of  local  affections  of  first  dentition  ought  to  be 
simple  when  they  are  the  only  ones  which  occur.  Van  Swieten 
is  one  of  the  authors  who  has  given,  with  great  plainness,  the  in- 
dications which  should  be  followed  in  such  cases  ;  therefore  the 
method  of  treatment  which  I  propose  to  recommend  may  be  con- 
sidered, in  some  respects,  but  kind  of  translation  from  this  author 
on  the  same  subject. 

It  is  necessary,  says  Boerhaave,  to  soften,  sooth,  and  refresh 
the  gums  with  emollients,  mucilages,  and  antiphlogistics,  and  to 
make  use  of  hard,  smooth  bodies,  or  to  make  incisions  in  them 
by  means  of  a  lancet.— (Aph.  1377.) 

This  aphorism  contains  the  sum  of  all  the  means  advised  by 

*  Comm.  in  Boerhaave,  aphor.  de  morbi  infant. 

1 1  have  not  seen  the  inflammation  of  the  germs  of  the  teeth ;  yet  Baglini,  Moreau 
de  la  Sarthe,  and  M.  Oudet  have  given  examples  of  it. 


ON   THE    DISEASES   OF    INFANTS*  209 

authors  to  favor  the  eruption  of  the  teeth.  But  the  commentator 
of  this  illustrious  writer j  in  developing  his  precepts,  apparently 
opposes  or  disapproves  them. 

Thus,  he  advises  the  use  of  emollients  and  mucilages  to  calm 
the  irritation,  and  he  recommends,  among  other  preparations,  a 
mixture  of  cream,  the  white  of  egg,  and  syrup  of  violets;  the 
mixture  may  be  rendered  more  liquid  by  the  addition  of  rose  wa- 
ter. It  may  be  applied  to  the  mouth  by  means  of  a  piece  of  lintj 
and  without  doubt  will  be  found  very  useful  in  the  treatment  of 
acute  inflammation  of  the  gums.  The  root  of  marshmallows  sa- 
turated with  syrup  may  be  given  to  the  infant  to  chew  with  ad^ 
vantage.  If  there  should  occur  in  the  head  a  sanguineous  con- 
gestion giving  rise  to  serious  apprehensions  as  to  the  result,  it 
will  be  useful,  observes  Van  Swieten,  as  Harris  remarks^  to  apply 
a  leech  behind  the  angle  of  each  jaw.  The  extreme  irritability 
of  the  mouth  ought  also  to  be  taken  into  consideration,  and  no 
hot  drinks  or  food  be  given.  It  may  be  necessary  to  remove  the 
child  from  the  breast,  or  to  give  the  nurse  very  mild  nourish  ■ 
ment,  together  with  emollient  drinks.  She  should  also  be  re 
quired  to  abstain,  during  the  period  of  dentition  in  her  charge 
from  the  use  of  wine  and  other  stimulating  drinks. 

As  to  the  employment  of  hard  substances  between  the  gums 
for  the  purpose  of  making  a  passage  for  the  teeth,  Van  Swieten 
has  not  rejected  them,  and  in  this  he  is  wrong ;  and  M.  Gardien 
has  clearly  demonstrated  that  their  use  is  by  no  means  rational. 
It  has  been  said  that  it  diverts  the  pain  of  the  teeth,  and  that  it 
is  seconding  the  desires  of  nature,  which  inspires  the  child  with 
a  constant  wish  to  carry  to  its  mouth  every  thing  given  to  it. 
But  is  the  patient  who  is  affected  with  the  itch,  and  who  tears  the 
skin  with  the  violence  of  scratching  to  calm  the  irritation,  in 
obeying  the  counsel  which  nature  appears  to  dictate  to  him  for 
the  assuaging  of  his  distress — is  he  following  a  rational  indica- 
tion, and  is  he  sooner  cured  of  his  disease  ?  Let  us  guard  then 
against  the  use  of  these  pretended  inspirations  of  nature  a  vague 
term,  and  better  suited  for  the  vulgar  than  for  physicians.  If,  as 
is  of  daily  observation,  the  infant  sleeps  when  the  nurse  gently 
rubs  the  end  of  her  finger  over  the  irritated  gum,  it  is  because  the 
pressure  is  extremely  gentle,  and  the  pleasurable  sensations  there- 
by produced  assuage  the  pain  of  the  gums.     But  this  is  far  differ- 

27 


210  ON   THE    DISEASES    OP    INFANTS. 

ent  from  the  introduction  of  a  coral,  crystal,  ivory,  or  amber. 
Let  us  reject  all  these  useless  means,  and  leave  them  in  the  obli- 
vion to  which  the  good  sense  of  the  present  day  has  condemned 
the  necklaces,  bracelets,  and  amulets. 

The  question  upon  the  necessity  of  cutting  the  gums  in  order 
to  facihtate  the  eruption  of  the  teeth,  a  practice  which  is  at  this 
time  much  followed  in  England,  has  been  much  agitated.  Yan 
Swieten  again  gives  upon  this  occasion  a  wise  precept.  It  is  not 
necessary,  he  says,  to  make  an  incision  in  the  gums  until  they 
are  evidently  raised  by  the  teeth,  are  hard,  red,  and  very  painful ; 
for  if  the  tooth,  too  deeply  situated,  does  not  soon  protrude 
through  the  incision,  the  latter  cicatrizes  ;  and  the  cicatrix,  harder 
than  the  proper  tissue  of  the  gums,  afterwards  affords  a  strong 
resistance.  Besides,  the  physician  might  endanger  his  reputa- 
tion should  he  chance  to  cut  the  gum  without  the  subsequent 
appearance  of  the  tooth.  I  saw  a  case,  says  Van  Swieten,  where 
a  tooth  did  not  make  its  appearance  until  eight  months  after  the 
incision  had  been  made  to  hasten  its  protrusion.  The  incision 
also  may  become  a  troublesome  ulcer,  which,  assuming  all  the 
characters  of  aphthous  or  gangrenous  ulcers,  may  thus  produce 
an  obstinate  and  painful  affliction  of  the  mouth. 

I  have  not  spoken  here  of  the  treatment  of  general  affections 
connected  with  dentition,  as  I  will  consider  them  in  the  place 
proper  for  the  examination  of  each  of  these  diseases.  * 

Section  III. 

DISEASES    OF   THE   SALIVARY    GLANDS. 

The  salivary  glands  are  rarely  diseased  in  young  infants ;  they 
do  not  grow  rapidly,  nor  exhibit  any  functional  activity,  except 
at  the  time  of  the  appearance  of  the  first  teeth.  I  have  often 
dissected  them  at  this  period  to  ascertain  precisely  their  condition, 
but  without  being  able  to  discover  any  thing  worthy  of  remark. 
Yet  I  have  often  met  with  the  parotid  gland,  or  the  granula- 
tions composing  it,  bathed,  as  it  were,  with  blood.  This  condition 
was  connected  with  a  sanguineous  congestion  of  all  the  surround- 
ing parts. 

*  See  Appendix,  page  571. 


ON   THE    DISEASES   OP    INFANTS.  211 

I  have  seen  at  the  Hospice  des  Enfans  Trouves,  one  case  of 
congenital  raniila.  The  child,  a  female,  was  brought  to  the 
hospital  during  the  night  ;  she  was  healthy  and  strong  ;  upon 
crying,  the  tongue  was  raised,  and  exhibited  a  transparent  tumor 
on  the  left  of  the  froenum,  resting  on  the  internal  face  of  the  jaw. 
This  tumor  was  irregularly  oblong,  and  occupied  exactly  the 
place  of  the  submaxillary  gland ;  it  was  very  elastic,  did  not 
empty  itself  on  pressure,  and  appeared  more  full  when  the  child 
was  not  crying.  M.  Baron,  who  examined  this  tumor  with  close 
attention,  did  not  hesitate  to  express  as  his  opinion,  that  it  was 
the  result  of  an  accumulation  of  saliva  secreted  by  the  sublingual 
gland,  the  orifices  of  which  were  without  doubt  obstructed. 

This  fact,  with  others  which  I  shall  point  out  in  the  course  of 
this  work,  proves  that  the  secreted  fluids  of  certain  glands,  how 
slightly  developed  soever  they  may  be,  even  during  intra-uterine 
existence,  must  have  a  passage  to  the  outside  of  the  gland. 

This  child  having  been  taken  to  the  country  two  days  after,  it 
was  impossible  to  ascertain  the  ulterior  progress  of  this  disease. 

Section  IV. 

DISEASES  OF  THE  GUTTURAL  PORTION  OF  THE  DIGESTIVE   TUBE. 

I  propose  in  this  place  to  consider  the  affections  of  the  velum, 
and  pillars  of  the  palate,  of  the  tonsils,  and  of  the  pharynx. 

Congenital  malformations.  The  malformations  of  the  velum 
consist  more  particularly  of  a  division,  to  a  greater  or  less  ex- 
tent. I  have  already  spoken  of  this  subject,  and  have  also  noted 
the  effects  which  follow  from  it,  and  the  precautions  necessary 
to  be  taken  during  the  sucking  of  the  child.  I  have  never  ob- 
served that  its  length  in  any  degree  hindered  deglutition,  and 
that  a  removal  of  part  of  the  uvula  was  necessary  in  young 
infants. 

Alterations  in  the  form  of  the  pharynx  are  the  only  changes 
which  I  have  noticed  ;  for  on  examining  dead  bodies  of  children, 
the  pharynx  has  sometimes  been  found  very  narrow  ;  we  might 
be  led  to  the  belief  that  this  was  the  result  of  a  state  of  contraction 
cf  the  constrictor  muscles,  but  the  base  of  the  tongue  was  also 
found  narrowed,  and  the  cornua  of  the  os  hyoides  were  approx- 
imated, so  that  it  was  very  probable  that  this  narrowness  depend- 


212  ON   THE    DISEASES    OF    INFANTS. 

ed  on  a  malformation.  If  it  exist  to  a  great  degree,  the  effect  is 
a  considerable  difficulty  in  swallowing,  as  we  have  seen  was  the 
case  in  the  infant  described  in  case  ix.  If  therefore  a  young 
infant  exhibit  much  difficulty  in  swallowing  the  milk  which  it 
drinks  or  sucks,  before  concluding  that  this  is  an  evidence  of  a 
phlegmasia  of  the  organs  of  deglutition,  it  will  be  necessary  to 
examine  with  attention  the  form  of  the  tongue,  the  narrowness 
of  which  is  almost  an  evidence  of  the  narrowness  of  the  pha- 
rynx. This  examination  is  not  without  its  utility,  because  the 
physician  can  then  confine  his  treatment  to  advising  that  drinks 
be  given  with  caution,  and  in  small  quantities  at  a  time,  while 
in  the  former  case  he  ought  to  use  all  the  means  in  his  power 
for  the  treatment  of  the  inflammation. 

SANGUINEOUS  CONGESTION  OF  THE  ORGANS  OP  DEGLUTITION. 

The  veil  of  the  palate,  and  the  isthmus  of  the  fauces  in  young 
children  are  almost  altogether  injected  and  red.  The  pharynx 
is  generally  in  a  high  state  of  congestion,  and  this  congestion  is 
the  more  considerable  in  proportion  to  the  nearness  to  birth.  I 
do  not  know  to  what  cause  to  attribute  this  condition.  It  is  a 
fact  to  which  the  attention  of  physicians  ought  to  be  directed^ 
because  it  may  very  easily  be  mistaken  for  an  inflammation  of 
these  parts.  I  have  examined  the  pharynx  with  great  care  in  a 
large  number  of  young  infants,  and  obtained  from  this  examina- 
tion the  following  data : 

In  two  hundred  children,  aged  from  one  to  ten  days,  that  had 
died  from  various  diseases,  I  found  the  isthmus  of  the  fauces  in- 
jected in  one  hundred  and  ninety.  This  injection  was  generally 
spread  in  a  uniform  manner,  but  sometimes  it  appeared  in  the 
form  of  ramifications  more  or  less  distinct.  I  did  not  find  any 
relation  worthy  of  note  existing  between  it  and  the  intestinal 
canal  ;  but  this  was  not  the  case  with  reference  to  the  duration 
and  intensity  of  the  congestion,  and  the  redness  of  the  integu- 
ments which  exists  in  young  infants  during  the  first  eight  or  ten 
days  of  their  life.  There  appeared  to  me  to  be  an  intimate  con- 
nection between  the  vascular  system  of  the  skin  and  that  of  the 
mouth  and  isthmus  of  the  fauces,  since  these  parts  exhibit  at  the 
period  of  birth  a  sanguineous  congestion,  the  duration  of  which 


ON    THE    DISEASES   OF    INFANTS.  213 

IS  the  same,  and  for  the  existence  of  which  there  appears  to  be 
no  pathological  cause.  The  same  phenomenon  appears  in  all 
infants  under  all  circumstances.  This  remark  will  bring  to  mind 
the  analogy  of  sensibility  and  irritability  that  authors  have  recog- 
nised between  the  cutaneous  system  and  mucous  membrane  of 
the  throat— an  analogy  which  demonstrates  in  a  very  evident 
manner  the  development  of  an  anginose  affection  at  the  com- 
mencement, or  during  the  progress  of  certain  cutaneous  phleg- 
masiae. 

The  tonsils,  although  but  little  developed  in  young  infants,  yet 
partake  of  the  same  state  of  congestion  as  the  surrounding  parts ; 
and  I  have  often  found  them  in  dead  bodies,  saturated  as  it  were 
with  the  blood  that  was  effused  around  them. 

INFLAMMATIONS. 

The  inflammation  of  that  part  of  the  digestive  tube  which  we 
are  now  considering,  has  been  designated  by  the  name  of  guttu- 
ral, pharyngeal,  or  tonsillar  angina. 

MM.  Roche  and  Sanson,  in  their  excellent  work,*  have  de- 
scribed the  various  localities  of  this  inflammation  under  the 
names  of  palatitis,  pharyngitis,  and  palato-pharyngitis  ;  but  as 
each  of  these  parts  is  rarely  the  exclusive  seat  of  the  inflamma- 
tion, which  generally  spreads  successively  to  all,  I  shall  devote 
to  their  history  but  one  chapter,  taking  care  to  point  out  their 
different  localities. 

Inflammation  of  the  velum  of  the  palate,  or  palatitis,  is  of  frequent 
occurrence  in  young  infants  ;  it  may  be  simply  ery thematic,  or 
may  be  accompanied  with  the  altered  secretion  constituting  mu- 
guet.  In  this  case  it  almost  always  follows  stomatitis,  which 
often  spreads  by  the  continuity  of  tissue  even  to  the  velum  and 
uvula.  The  causes  are  the  same  as  those  of  inflammation  of  the 
mouth.  The  pellicle  which  then  covers  the  velum  palati  must 
not  be  confounded  with  the  false  membrane  of  croup,  the  princi- 
pal characters  of  which  it  appears  to  possess.  It  is  equally  im- 
portant not  to  mistake  it  for  a  gangrenous  eschar,  from  which 


*  Nouveux  elemens  de  pathologie  medico-chirurgicale,  5  vol.     Paris,  1828.     [This 
work  is  now  in  the  process  of  translation,  by  A.  Sidney  Doane,  M.  D. — S.] 


214  ON   THE    DISEASES    OF    INFANTS. 

indeed  it  essentially  differs.     The  worjvs  of  Guersent  and  Bre- 
tonneau  have  put  us  on  our  guard  against  this  last  mistake. 

The  tonsils  may  likewise  inflame  in  children  at  the  breast,  but 
tonsilitis  appears  to  me  less  frequent  at  this  age  than  at  a  more 
advanced  period  of  life.  Inflammation  of  the  tonsils  may  be 
simple,  and  not  characterized  by  any  thing  but  redness  and  tu- 
mefaction ;  it  may  be  complicated  with  an  altered  secretion,  a 
complication  which  is  of  very  frequent  occurrence.  It  is  not 
impossible  for  the  tonsils  to  ulcerate  and  be  destroyed  by  gan- 
grene ;  but  these  kinds  of  inflammations  are  very  rare  in  infants 
at  the  breast,  and  I  am  not  in  possession  of  any  example  of  such 
a  variety :  finally,  the  pharynx  itself  may  become  the  seat  of  all 
these  modifications  of  inflammation  which  we  have  just  men- 
tioned. 

It  will  sometimes  be  difiicult  to  recognise  ^  inflammation  of 
these  parts  in  young  infants,  as  the  ordinary  aspect  of  the  state 
of  congestion  has  a  great  resemblance  to  redness  of  inflamma- 
tion ;  yet  we  may  assist  our  diagnosis  by  the  following  consid- 
erations. 

The  isthmus  of  the  fauces  and  the  pharynx  may  be  considered 
as  inflamed — 1st,  When  the  duration  of  this  redness  continues  be 
yond  the  ordinary  time  of  the  disappearance  of  the  congestion  in 
young  infants,  ten  or  twelve  days,  for  example  ;  2dly,  When,  in- 
stead of  being  uniformly  spread  over  every  part  of  the  throat,  it 
occupies  separate  points  ;  3dly,  When  some  one  of  the  symptoms 
of  cynanche  tonsilaris,  which  we  will  mention  below,  exist  at 
the  same  time  as  the  redness ;  when,  lastly,  this  redness  is  met 
with  at  a  period  when  it  is  no  longer  a  natural  state  of  the  part. 
I  will  begin  the  symptomatology  of  inflammations  of  the  gut- 
tural region,  by  a  detailed  exposition  of  some  facts,  from  which 
I  will  deduce  the  history  of  the  symptoms  of  this  disease  in  young 
infants. 

CASE  XVII. — Paul  Bedquier,  aged  ten  days,  entered  the  infirma- 
ry on  the  25th  of  May,  1826.  He  had  been  very  restless  the  preced- 
ing night,  and  had  vomited  several  times  ;  his  nurse  remarked  that 
he  had  sucked  badly  often  loosing  his  hold  on  the  nipple,  crying, 
and  vomiting  the  milk  he  had  taken.  The  deglutition  was  often  so 
difficult  as  to  produce  a  convulsive  movement  in  the  superior  extre- 


ON   THE  DISEASES   OF    INFANTS.  215 

mities.  His  cry  was  natural  and  strong ;  there  was  no  fever  present. 
(Sweetened  decoction  of  the  Tilia,  with  half  a  drachm  of  syrup  of 
poppies  to  two  ounces  of  the  infusion ;  milk  and  water  for  nourish- 
went.)  The  next  day,  M.  Baron  saw,  on  examining  the  mouth,  that 
the  base  of  the  tongue,  the  velum,  and  fauces,  were  very  red  ;  and  he 
Avas  of  the  opinion  that  the  disease  was  an  inflammation  of  the  pha- 
rynx. The  child,  however,  became  more  calm  and  ceased  to  vomit. 
The  nurse  having  charge  of  this  child  administered  the  drinks  with 
caution,  for  she  had  observed  that  the  child  drank  awkwardly.  This 
patient  remained  some  time  in  the  infirmary  without  presenting  any 
remarkable  symptom  ;  on  the  25th  of  May  he  had  a  slight  puriform 
ophthalmia  which  lasted  but  a  few  days.  On  the  6th  of  January,  a  few 
points  of  muguet  appeared  on  the  borders  of  the  tongue,  which 
quickly  disappeared.  It  was  observed  that  deglutition  was  always 
diflicult,  and  that  it  was  necessary  to  give  the  drinks  with  caution. 
The  pulse  was  natural,  and  the  temperature  of  the  skin  as  usual. 
(Sweetened  barley-water,  emollient  gargles,  milk  and  water.) 

On  the  14th  of  June,  it  was  observed  that  the  child  had  become 
emaciated  and  pale,  and  the  face  a  little  infiltrated.  For  some  days 
he  had  been  affected  with  a  copious  diarrhoea,  consisting  of  yellow 
liquid  discharges.  This  state  continued  until  the  20th  of  July,  when 
he  died. 

The  post  mortem  examination  was  made  the  next  day,  when  there 
was  found  a  very  intense  redness,  and  evident  tumefaction  of  the 
internal  membrane  of  the  pharynx.  The  surrounding  cellular  tis- 
sue was  infiltrated  with  a  considerable  quantity  of  citron-colored  se- 
rum ;  the  oesophagus  and  stomach  were  healthy.  At  the  termina- 
tion of  the  ileon  there  existed  several  follicles,  slightly  injected,  and 
the  termination  of  the  colon  was  of  a  slate  color.  The  liver  was  of 
a  deep  brown,  and  filled  with  a  black  liquid  blood.  The  lungs  were 
much  injected,  with  some  red  striae  at  the  internal  surface  of  the 
bronchiee  and  of  the  trachea.  The  nasal  fossae  were  very  red,  and 
filled  with  recently  effused  blood.  The  brain  exhibited  nothing  re- 
markable. 

This  child,  without  doubt,  died  from  a  chronic  colitis ;  but  in 
addition  to  this,  he  was  affected  with  inflammation  of  the  pha- 
rynx, the  symptoms  of  which  were  very  evident  during  life.  We 
ought  also  to  notice  that  the  cry  of  the  child  was  not  altered,  and 
the  act  of  deglutition  alone  was  performed  with  pain.     Febrile 


216  ON  The  diseases  op  infants. 

symptomSj  which  always  attend  anginose  inflammations  in 
adults,  were  absent  in  this  case,  and  must  be  attributed  to  the  age 
bf  the  patient. 

On  the  preceding  instance,  the  velum  and  pharynx  were  the 
seat  of  the  inflammation ;  we  shall  see  in  the  following  case, that 
the  phlegmasia  was  confined  solely  to  the  walls  of  the  pharynx. 

CASE  XVIII. — Molard,  a  boy  aged  seventeen  days,  entered  the 
infirmary  on  the  26th  of  January,  for  muguet  of  the  mouth,  without 
any  serious  symptom.  (Gummed  barley-water,  gum-syrup,  errcol- 
lient  gargle,  milk  and  water.)  On  the  1st  of  February,  the  muguet 
had  disappeared,  but  the  child  cried  frequendy,  slept  but  little,  and 
became  emaciated  without  having  any  diarrhoea.  He  vomited  almost 
as  soon  as  he  had  taken  his  milk  or  his  ptisan ;  there  was  nothing 
remarkable  in  the  deglutition  ;  the  abdomen  was  neither  painful  nor 
swelled.  On  the  5th  of  February,  the  vomiting  returned  with  greater 
frequency,  almost  immediately  following  deglutition.  The  velum 
was  healthy,  and  the  tongue  a  little  red  ;  the  infant  became  pale,  and 
the  lower  extremities  were  hard  and  (Edematous.  [Sweetened  rice- 
water,  milk  and  water.)  On  the  following  day,  the  abdomen  be- 
came swelled,  a  copious  diarrhoea  succeeded,  and  death  took  place 
on  the  12th  of  February. 

Post  mortem  examination. — The  tongue  was  very  red;  the  ve- 
lum healthy,  but  the  mucous  membrane  of  the  pharynx  of  an  intense 
red,  and  covered  with  a  considerable  quantity  of  frothy  mucus, 
strongly  adherent.  This  redness  disappeared  at  the  commencement 
of  the  oesophagus,  the  membrane  of  which  was  of  a  delicate  rose 
color.  The  stomach  was  perfectly  healthy,  and  contained  a  quantity 
of  ropy  mucus.  The  ileo-caecal  region  of  the  small  intestines  ex- 
hibited a  uniform  redness,  in  the  midst  of  which  was  a  sanguinolent 
exudation.  The  large  intestines  were  healthy;  the  lungs  crepitated 
well;  the  heart  contained  but  little  blood  ;  the  ductus  arteriosus  was 
obliterated,  but  the  foramen  ovale  was  still  open.  The  occipital  si- 
nus was  gorged  with  blood ;  the  cerebral  pulp  was  of  a  rose  color ; 
there  was  but  little  serum  in  the  ventricles. 

This  case  is  but  of  secondary  interest ;  for,  in  spite  of  the  in- 
flammation of  the  pharynx,  there  was  scarcely  any  thing  besides 
the  vomiting  immediately  after  deglutition,  which  gave  any  in- 
dication of  the  seat  and  nature  of  the  disease.     I  have  given  it  a 


ON    THE    DISEASES   OF    INFANTS.  217 

place  here  because  the  least  important  facts  in  a  science  of  obser- 
vation are  of  consequence. 

We  have  thus  far  recorded  nothing  but  cases  of  erythematic 
inflammation  of  the  pharynx  ;  we  shall  now  give  an  example  of 
phlegmasia  of  the  velum,  tonsils,  and  pharynx,  with  altered  secre- 
tion. 

CASE  XIX.— Augustine  Blondel,  aged  twelve  days,  entered  the 
infirmary  on  the  13th  of  July.  This  child  was  very  vigorous.  She 
refused  the  breast,  cried  incessantly,  and  slept  none.  The  cry  was 
husky  and  laborious,  respiration  difficult,  face  purple,  and  neck  aUt- 
tle  tumefied.  On  examining  the  mouth,  the  velum  alone  was  found 
a  little  red.  There  neither  existed  any  sensible  acceleration  of  the 
pulse  nor  heat  of  skin.  (Gummed  barley-water,  emollient  gargle, 
two  leeches  to  each  side  of  the  neck,  strict  diet.)  On  the  fourteenth, 
several  spots  of  muguet  appeared  on  the  tongue,  and  all  the  buccal 
membrane  was  of  an  intense  red  ;  there  were  also  several  patches  of 
muguet  on  the  velum,  the  redness  of  which  was  much  increased. 
The  tonsils,  which  were  red  and  very  much  tumefied,  were  covered 
with  a  slight  membranous  exudation.  There  existed  no  fever  ;  the 
heat  of  the  skin  was  natural ;  the  face  continued  purple  ;  the  cry  was 
painful,  but  the  respiration  less  difficult.  Deglutition  was  almost 
impossible.  [Cataplasm  to  the  neck,  blister  to  the  legs,  barley-wa- 
ter for  drink  and  for  a  gargle.)  On  the  fifteenth,  there  was  no  fe- 
ver, pulse  ninety,  cry  smothered,  respiration  difficult ;  the  child  was 
more  afiected  with  regurgitations  than  with  vomiting.  On  the 
eighteenth,  the  muguet,  less  abundant  in  the  mouth,  formed  upon  the 
pillars  of  the  palate  and  on  the  tonsils  an  accumulation  so  thick  that 
there  existed  only  a  very  narrow  passage.  The  cry  was  less 
smothered  ;  both  parts  of  it  were  heard,  but  the  reprise  was  acute 
and  tremulous,  and  sometimes  interrupted,  in  some  respects  analo- 
gous to  the  crowing  of  a  cock.  The  face  was  less  purple.  On  the 
nineteenth,  the  cry  was  less  husky,  and  approached  more  to  the  na- 
tural state  ;  respiration  was  more  full ;  the  face  was  pale  and  expres- 
sive of  pain.  [Continued  the  blisters  and  emollient  drinks.)  On 
the  twentieth,  the  tonsils  were  freed  from  the  coating  of  muguet ; 
they  were  still  red,  but  their  tumefaction  was  less.  Deglutition  was 
difficult,  and  it  was  necessary  to  give  the  drinks  by  drops.  When 
the  fauces  were  examined,  several  spots  of  muguet  were  to  be  -se'efi 
in  the  pharynx.  From  the  twentieth  to  the  twenty-fifth,  the  health 
of  the  child   rapidly  increased,  and  deglutition  became  more  easy. 


218  ON   THE    DISEASES    OP    INFANTS. 

Milk  and  water  was  given  for  nourishment.  On  the  thirtieth,  the 
cure  was  complete,  although  the  tonsils  were  still  very  red.  Deglu- 
tition was  easily  performed  ;  the  circulation  soon  arrived  at  its  healthy 
state,  and  the  face  regained  its  color.  The  infant  was  placed  in 
charge  of  the  ordinary  nurse  on  the  3d  of  August,  and  left  the  hos- 
pital for  the  country  on  the  eleventh  of  the  same  month,  completely 
restored  to  health. 


This  inflammation  of  the  tonsils  and  pharynx  was,  without 
doubt,  complicated  with  laryngitis,  if  we  may  judge  from  the 
alteration  of  the  cry  and  the  difficulty  of  respiration.  But  inde- 
pendently of  this  complication,  we  must  not  lose  sight  of  other 
symptoms,  such  as  regurgitation,  tumefaction  of  the  neck,  and 
the  refusal  of  the  breast,  because  the  infant  could  not  swallow 
without  pain.  We  should  also  consider  the  success  of  the  anti- 
phlogistic treatment  adopted  by  M.  Baron,  unusual  in  an  hospital, 
and  at  an  age  when  so  many  morbid  causes  counteracted  the  ef- 
forts of  the  physician  ;  the  case  is  not  the  less  interesting  with 
reference  to  the  alteration  in  the  cry,  caused,  no  doubt,  by  the  for- 
mation and  the  extension  of  the  pellicle  of  muguet  on  the  tonsils, 
and  probably  on  the  glottis. 

It  will  be  useless  to  multiply  examples  of  inflammation  of  the 
velum,  tonsils,  and  pharynx.  I  shall,  therefore,  give  a  synopsis 
of  the  symptoms  of  this  disease. 

When  the  inflammation  of  these  organs  is  slight,  their  func- 
tions are  but  little  disturbed.  But  when,  on  the  contrary,  there 
is  some  degree  of  intensity,  deglutition  is  difficult,  and  when  ac- 
complished, it  is  quickly  followed  by  regurgitations  or  vomiting, 
even  when  the  oesophagus  and  stomach  are  healthy,  as  we  have 
seen  in  eighteenth  and  nineteenth  cases.  Therefore,  if  we  see  a 
child  refuse  the  breast,  swallow  with  difficulty  what  is  given  it 
to  drink,  or  when  the  face  expresses  pain  on  swallowing,  it  should 
then  be  the  duty  of  the  physician  to  examine  the  fauces,  to  ascer- 
tain whether  it  is  not  the  seat  of  an  erythematic  inflammation 
with  altered  secretion.  If  the  neck  is  tender  and  painful  to  the 
touch  ;  if  the  child  cries  out  when  this  part  is  examined ;  if,  af- 
ter these  symptoms,  there  succeeds  a  tumefaction  of  the  tonsils, 
ah  alteration  of  the  cry  and  of  the  physiognomy,  we  ought  then 
td'be.satisfied  of  the  existence  of  cynanche  tonsilaris,  or  inflaiiir 


ON   THE    DISEASES    OP    INFANTS.  219 

mation  of  the  pharynx.     I  have  never  been  sensible  of  the  odor 
which  is  observed  in  adults  in  similar  cases. 

Treatment. — In  the  first  place,  the  child  ought  not  to  be  al- 
lowed to  suckj  because  it  generally  sucks  with  such  avidity  as 
to  have  a  large  quantity  of  milk  carried  to  the  throat  at  one 
time.  It  is  much  better  to  feed  the  child  either  with  a  spoon  or  a 
sponge ;  to  wash  the  mouth  with  a  pledget  of  lint  soaked  in  a 
decoction  of  marshmallows.  The  neck  should  be  enveloped  in 
a  cataplasm,  and  one  or  two  leeches  applied  on  the  sides  of  the 
pharynx,  if  the  inflammation  be  very  intense,  using,  at  the  same 
time,  revulsives  to  the  legs  or  feet,  either  by  means  of  a  hot  cata- 
plasm almost  burning,  or  with  a  mustard  poultice,  or  a  stimu- 
lating bath.  If  these  means  are  insufficient,  recourse  must  then 
be  had  to  blisters.  If  there  exist  no  symptoms  of  gastro-enteritis, 
injections  should  be  administered,  composed  of  a  decoction  of 
prunes,  or  a  mixture  of  equal  parts  of  milk  and  burned  sugar,  or 
one  or  two  grains  of  calomel  in  two  spoonsful  of  sweetened  wa- 
ter. But  these  derivations  ought  to  be  used  with  the  greatest 
caution,  for  it  is  very  rare,  as  we  shall  hereafter  prove,  that  one 
part  of  the  digestive  tube  alone  is  inflamed  in  young  infants.  If, 
after  the  employment  of  antiphlogistic  means,  the  child  continues 
tormented  by  pain  and  wakefulness,  opiates  must  be  resorted  to, 
especially  the  syrup  of  poppies,  taken  in  the  dose  of  half  a 
drachm  in  an  ounce  of  sweetened  water  in  the  space  of  two 
hours. 

I  think  it  altogether  useless  to  produce  vomiting  in  infants 
affected  with  tonsilitis,  for  there  already  exists  a  great  tendency 
to  vomiting,  which  appears  rather  to  augment  than  to  diminish 
the  disease.  An  antiphlogistic  treatment,  such  as  is  reported  in 
the  case  of  A.ugustine  Blondel,  answers  a  much  better  purpose. 

Section  V. 

DISEASES   OF   THE    OESOPHAGUS. 

Congenital  malformations. — The  malformations  of  the  oeso- 
phagus which  are  developed  during  intra-uterine  life,  and  which 
give  rise  to  serious  consequences,  are  not  very  numerous.  They 
generally  exist,  as  Meckel  says,  at  the  same  time  with  the  ab- 


220  ON    THE    DISEASES   OF    INFANTS. 

sence  or  default  of  conformation  of  one  part  or  several  parts  of 
the  face  or  mouth  ;  or,  as  in  the  Instance  related  by  M.  Lallemand 
of  Montpellier,  with  what  appears  to  have  been  the  destruction  or 
deviation  of  the  parts  which  surround  and  sustain  the  oesophagus 
in  its  natural  position. 

These  primitive  malformations  consist  in  the  absence  of  the 
oesophagus ;  in  the  obliteration  of  this  membranous  passage,  termi- 
nating in  a  cul-de-sac  ;  or  in  a  division  of  a  part  of  the  oesophagus 
in  two  passages  placed  the  one  beside  the  other. 

The  following  is  a  remarkable  instance  of  absence  of  the  oeso- 
phagus. 

The  subject  of  this  case  was  born  at  the  full  time,  destitute  of 
the  oesophagus.  It  lived  eight  days,  and  was  observed  by  Dr. 
Sonderland  at  Barmen. 

On  the  2d  of  August  Madame  B was  delivered  of  a  child 

at  the  full  time,  and  who  appeared  in  good  health  and  well 
formed.  After  the  accouchment,  there  was  a  large  discharge  of 
water,  and  the  placenta  was  two  or  three  times  the  ordinary 
size.  A  small  quantity  of  sweetened  water  was  given  to  the 
child,  which  it  swallowed  greedily,  but  the  fluid  returned  imme- 
diately through  the  nose  and  mouth,  almost  producing  suffoca- 
tion. Endeavors  were  repeatedly  used  to  make  it  swallow  some 
kind  of  drink,  but  without  avail,  the  same  effect  constantly  fol- 
lowed every  attempt,  whence  it  was  natural  to  infer  that  some 
kind  of  malformation  existed  in  the  oesophagus.  This  child  lived 
eight  days,  at  the  end  of  which  period  it  died  of  hunger.  During 
its  life  the  urine  and  foeces  passed  as  they  usually  do,  except  in 
smaller  quantities.  On  opening  the  body,  the  most  remarkable 
thing  that  appeared  was  the  extraordinary  size  of  the  liver,  cover- 
ing: all  the  viscera  of  the  abdomen  to  the  umbilicus,  but  in  other 
respects  quite  natural.  The  gall-bladder  was  filled  with  bile. 
Upon  raising  the  liver,  the  stomach  and  intestines  were  found  of 
the  usual  conformation,  and  their  situation  was  the  same  as  usual, 
but  the  cardiac  orifice  was  wanting,  and  in  this  place  the  stomach 
adhered  to  the  diaphragm  by  cellul  ar  tissue.  The  right  lung  was 
distended,  and  was  of  a  rose  color  ;  the  left,  on  the  contrary,  was 
dense  in  structure,  and  of  a  deeper  hue,  proving  that  the  child  had 
only  respired  with  the  former.  The  heart  was  well  formed,  except 
that  the  septum  of  the  auricles  was  open.     The  oesophagus  was 


ON   THE    DISEASES    OF    INFANTS.  221 

wanting  the  whole  of  its  length,  and  the  pharynx  terminated  in  a 
cul-de-sac* 

The  most  remarkable  case  of  the  termination  of  the  oesophagus 
in  a  cul-de-sac,  and  without  any  communication  with  the  sto- 
mach, is  that  recorded  in  the  inaugural  dissertation  of  M.  Lalle- 
mand,  of  an  anencephalic  foetus  born  at  the  Hotel  Dieu  in  1816. 

"In  examining  the  traces  of  the  brain,"  says  M.  Lallemand, 
"  we  found  behind  the  neck,  below  the  sphenoid  bone,  a  white, 
resisting  spherical  body,  which  was  regarded  as  the  cerebellum, 
and  which  was  covered  with  a  fold  of  the  dura-mater,  which  forms 
the  tentorium.  But,  after  having  cut  into  the  exterior  membrane, 
we  were  much  surprised  to  see  a  green  substance  of  some  con- 
sistence, resembling  the  meconium  in  every  respect,  issue  from  a 
sort  of  sac-like  cavity;  the  resemblance  was  so  perfect  that  it 
was  the  first  comparison  that  occurred  to  the  minds  of  those  who 
were  present." 

"  The  internal  surface  of  this  sac  had  all  the  appearance  of  a 
mucous  membrane ;  it  was  in  truth  that  of  the  pharynx  and 
oesophagus.  This  was  ascertained  by  passing  a  probe  from  the 
bottom  of  this  cavity  across  the  vertebral  column  out  at  the 
month.  The  oesophagus  had  protruded  in  crossing  an  opening, 
and  thus  forming  a  fold,  like  a  portion  of  intestine  in  hernia.  The 
cavity  was  considerably  dilated  by  the  accumulation  of  meconium. 
Just  before  entering  the  thorax,  the  oesophagus  was  shrunk,  and 
even  obliterated  to  such  a  degree  that  I  could  not  pass  the  finest 
probe  into  the  stomach,  while  a  very  large  one  could  be  passed  by 
the  mouth  without  difiiculty."t 

This  malformation,  remarkable  as  it  is  in  several  respects,  does 
not  assist  our  diagnosis  of  a  similar  affection  ;  for  the  child  thus 
affected  was  not  viable,  and  consequently  did  not  present  any 
sign  by  which  the  nature  of  the  disorder  could  be  ascertained  ; 
but  from  the  preceding  case  we  are  able  to  point  out  what  would 
be  the  signs  of  obliteration  of  the  oesophagus  of  a  new-born  child. 

Deglutition,  in  the  first  place,  would  be  altogether  impossible  ; 
the  child  quickly  vomits  its  milk,  and  when  the  cul-de-sac  result- 


*  Journal  complevient.  du  Diet,  des  sciences  med.  t.  8,  p.  369. 
t  Observationcs  pathol.  propres  d  eclairer  quelqucs  points  de  physiologic.     Paris, 
1818. 


222  ON    THE    DISEASES    OP    INFANTS. 

ing  from  the  obliteration  is  filled,  a  soft  tumefaction  which  aug- 
ments at  each  attempt  at  deglutition  is  very  evident ;  and  after  this 
sac  is  emptied,  nausea  continues ;  the  child  making  the  same 
useless  attempts  at  vomiting  as  is  observed  in  dogs  when  they  have 
been  poisoned,  and  when  the  oesophagus  has  been  tied  in  order 
to  prevent  the  vomiting  of  the  poisonous  substance. 

What  treatment  should  be  adopted  in  such  cases  1  It  is  with- 
out doubt  extremely  difficult  to  remedy  this  deficiency,  and  a 
hope  can  scarcely  be  indulged  of  saving  a  child  thus  condemned 
to  almost  certain  death ;  yet  as  it  may  sometimes  be  of  great  im- 
portance that  the  child  should  live  for  a  few  hours  or  days  on  ac- 
count of  the  succession  in  families  depending  on  the  establishment 
and  duration  of  life,  the  physician  ought  to  use  all  the  means  in 
his  power  for  its  prolongation  to  as  long  time  as  possible.  He 
will  therefore  endeavor  to  sustain  the  child  by  injections  of  milk, 
or  a  mixture  of  equal  parts  of  milk,  and  thick  broth.  In  addition 
to  these  means,  attempts  ought  to  be  made  to  ascertain  whether 
the  oesophagus  be  altogether  closed,  and  whether  a  gum  elastic 
catheter  could  not  be  introduced  into  the  stomach,  by  which 
some  liquid  nourishment  might  be  conveyed  into  the  digestive 
passages.  This  catheter  might  also  seem  to  dilate  gradually  the 
oesophageal  canal. 

Although  advising  these  means,  yet  I  very  much  doubt  their 
efficacy,  and  the  cure  of  so  great  a  derangement  can  hardly  be 
expected,  except  in  the  case  of  the  obliteration  being  but  partial, 
otherwise  it  must  be  almost  a  miracle. 

Alterations  of  texture  developed  daring  intra-uterine  life. — 
In  order  to  appreciate  properly  these  alterations,  it  is  necessary 
to  have  an  exact  idea  of  the  Q3Sophagus  in  a  young  infant.  I 
examined  this  membranous  canal  with  much  care  in  almost  all 
the  children  that  died  during  the  year  1826  at  the  Hospice  des 
Enfans  Trouves.  In  about  two  hundred,  where  there  was  reason 
to  believe  that  this  organ  was  healthy,  I  found  it  more  or  less 
injected  in  one  hundred  and  ninety — that  is  to  say,  in  the  same 
children  of  whom  I  have  already  spoken  as  having  exhibited  the 
injection  of  the  pharynx,  this  injection  presented  different  aspects, 
but  it  rarely  had  a  ramiform  appearance.  It  was  more  generally 
of  a  uniform  color,  varying  from  a  bright  red  to  a  violet,  and 
always  terminated  abruptly  at  the  place  where  the  epithelium 


ON    THE    DISEASES    OF    INFANTS.  223 

entirely  ceases.  My  remarks  with  reference  to  the  habitual  red- 
ness of  the  pharynx  are  applicable  to  the  oesophagus;  both  appear 
to  me  to  be  natural  in  new-born  children,  and  this  congestion  is 
doubtless  owing  to  the  same  cause  as  that  of  the  general  injection 
of  the  external  integuments,  and  ought  not  to  be  considered  as  a 
pathological  condition,  since  it  is  to  be  observed  in  all  young 
*nfants.  M.  Baron,  who  has  for  a  long  time  noticed  this  habitual 
redness  of  the  oesophagus  of  young  infants,  has  never  regarded 
it  as  pathological ;  and  I  think  that  it  is  the  eifect  of  the 
passive  congestion  resulting  from  the  imperfect  establishment 
of  respiration  and  circulation. 

But  if  besides  the  injection  and  redness  which  we  have  pointed 
out  as  existing  in  the  oesophagus,  we  find  an  alteration  of  a  more 
serious  nature  in  the  internal  membrane  of  this  canal  in  a  young 
infant,  such  alteration  must  be  regarded  as  the  result  of  some 
slight  morbid  cause.  Let  us  endeavor  to  demonstrate  the  truth 
of  what  has  been  advanced  by  some  examples. 

CASE  XX. — Deher  entered  the  Hospice  des  Enfans  Trouves 
on  the  20th  of  March.  In  this  child,  who  was  a  male,  the  umbilical 
cord  was  soft  and  fresh,  and  had  been  recently  tied.  The  clothes 
were  already  stained  by  the  meconium,  and  there  had  been  vomiting 
of  glairy  matters  ;  the  face  was  red  and  pinched,  and  the  extremi- 
ties cold,  yet  he  appeared  to  possess  a  good  constitution.  He  died 
on  the  night  of  the  28th.  The  post  mortem  examination  was  made 
twenty  hours  after  death.  The  mouth  and  pharynx  were  found  much 
injected.  Besides  this,  there  existed  in  the  whole  length  of  the  oeso- 
phagus a  considerable  number  of  mucous  follicles  very  much  deve- 
loped, and  which  for  the  most  part  were  surrounded  at  their  base  by 
a  red  circle,  more  vivid  than  the  general  red  and  violet  color  pre- 
sented by  the  parietes  of  the  pharynx  and  oesophagus.  Some  ot 
these  follicles  had  begun  to  ulcerate  at  their  summits,  exhibiting  a 
superficial  yellow  laceration.  The  same  alteration  was  met  with  in 
the  same  degree  in  the  stomach,  which  contained  brown  matters  of 
the  consistence  of  mucus.  They  adhered  closely  to  the  sides  of 
this  organ.  The  small  intestines  presented  a  strongly  marked  ve- 
nous congestion.  The  two  lungs  were  much  congested  with  blood. 
The  obliteration  of  the  foramen  ovale  and  the  ductus  arteriosus  had 
already  commenced;  there  existed  also  a  slight  congestion  of  the 
brain. 


224  ON   THE   DISEASES  OF    INFANTS. 

This  child  died  from  congestion  of  the  lungs,  but  besides  this 
cause  there  evidently  existed  another  affection,  that  of  the  folli- 
cular apparatus  of  the  oesophagus  and  stomach,  developed  proba- 
bly during  intra-uterine  life ;  for  it  had  not  had  sufficient  time  to 
make  so  great  a  progress  in  the  single  day  that  the  child  had 
lived.  The  following  case  exhibits  a  much  greater  alteration  in 
the  oesophagus. 

CASE  XXI. — Bouton,  a  boy  recently  born,  entered  the  hospital  on 
the  4th  of  April,  and  died  on  the  night  of  the  5th,  but  I  did  not  observe 
the  symptoms  which  he  presented.  It  was  simply  reported  to  me  that 
he  had  vomited  several  times  the  evening  before,  and  that  he  did  not 
appear  disposed  to  suck,  nor  did  he  long  retain  his  milk.  I  opened 
the  body  six  hours  after  death,  and  found  the  mouth  injected,  the  pha- 
rynx very  red,  and  the  internal  membrane  a  little  tumefied.  In  the 
upper  part  of  the  oesophagus  there  were  two  ulcerations,  almost  par- 
allel, of  an  oblong  shape,  each  being  about  four  lines  in  length  ;  their 
bases  were  yellow ;  their  borders,  which  were  perpendicular,  pre- 
sented, with  the  upper  third  of  the  oesophagus,  the  bright  color  of 
carmine  ;  the  stomach  and  the  entire  intestinal  tube  were  the  seat 
of  a  very  manifest  sanguineous  congestion,  with  a  sanguinolent  ex- 
udation in  the  whole  extent  of  the  digestive  canal.  The  liver  was 
easily  reduced  to  a  soft  mass ;  the  gall-bladder,  much  dilated,  con- 
tained black  and  tarry  bile. 

The  lungs  were  engorged,  and  a  considerable  quantity  of  sangui- 
neous serum  was  effused  in  the  thorax.  The  fcetal  openings  were 
still  free,  the  brain  was  found  very  much  injected,  and  there  was  an 
effusion  of  blood  between  the  tunica  arachnoidea  and  the  pia  mater. 
The  two  cerebral  ventricles  contained  bloody  serosity. 

Besides  the  general  sanguineous  congestion  which  in  this 
child  prevented  the  development  and  exercise  of  the  functions  of 
the  principal  organs,  it  is  evident  that  he  was  affected,  when  born, 
with  inflammation  and  ulceration  of  the  oesophagus,  an  affection 
of  a  very  serious  nature,  and  which  would  to  a  great  degree  im- 
pede the  action  of  deglutition,  and  thus  materially  interfere  with 
digestion  and  nutrition,  two  of  the  most  important  functions  of 
life. 

If  the  facts  just  cited  do  not  throw  much  light  on  the  symptom- 
atology of  03sophagitis,  they  still  prove  to  us  that  it  is  possible  for 
infants  to  be  born  with  infiammiation  of  the  oesophagus,  which 


ON    THE  DISEASES    OB'    INFANTS.  225 

may  be  to  them  the  source  of  very  serious  consequences,  to  the 
relief  of  which  the  physician  ought  to  apply  the  appropriate  reme- 
dies from  the  first  moments  of  life.  We  shall  next  consider  the 
history  of  oesophagitis  developed  after  birth  ;  and  our  remarks  on 
the  diagnosis  and  treatment  of  this  disease,  will  likewise  have 
reference  to  congenital  oesophagitis. 

DISEASES    OP    THE     CESOPHAGUS    DEVELOPED    Ai?^ER    BIRTH. 

When  treating  of  diseases  of  the  mouth  and  pharynx,  the  pro- 
gress of  the  alteration  in  those  diseases  being  submitted  to  actual 
inspection,  the  march  of  the  symptoms  accompanying  them 
were  clearly  seen  and  described  ;  but  such  an  inspection  cannot 
be  exercised  as  we  advance  to  the  lower  portions  of  the  digestive 
tube ;  we  are,  therefore,  obliged  to  take  another  course,  different 
from  the  one  hitherto  taken,  and  to  trace  the  diagnosis,  and  sug- 
gest the  treatment  of  the  diseases  about  to  be  considered  in  pro- 
portion as  the  facts  are  unveiled  to  us ;  for  this  is  not  a  work  of 
imagination — a  record  of  abstract  and  preconceived  ideas — but  it 
is  our  wish  to  be  a  close  and  faithful  interpreter  of  nature,  and  to 
speak  only  from  the  facts  before  us.  Let  us  begin  then  with  the 
history,  a  dry  one  it  is  true,  but  not  the  less  indispensable,  of  the 
facts  which  we  have  collected  in  relation  to  the  diseases  of  the 
oesophagus  of  new-born  children. 

Inflammations. — OEsophagitis  is  rare  in  adults  ;  its  common 
cause  is  the  swallov/ing  of  irritating  poisons.  Thus  oesophagitis 
is  almost  always  produced  by  poisoning  with  sulphuric  acid.  But 
this  disease  is  less  rare  in  young  infants ;  the  reason  of  which  is, 
that  this  organ  is  almost  always  the  seat  of  congestion  to  a 
greater  or  less  extent.  On  this  account  it  is  more  disposed  to  in- 
flammation and  disorganization.  When  inflammation  exhibits 
no  other  sign  than  redness,  it  will  be  extremely  difiicult  to  distin- 
guish it  from  the  habitual  congestion  of  the  oesophagus.  But 
when  with  this  redness  there  are  also  present  some  lesion  or  some 
of  the  products  of  phlegmasia,  no  doubt  ought  to  exist  that  the 
membrane  of  the  oesophagus  is  then  inflamed.  Thus,  the  symp- 
toms which  during  life  accompany  the  development  of  these 
lesions,  ought  to  be  considered  as  proper  to  oesophagitis,  and 
serve  to  settle  the  diagnosis  of  this  disease. 


226  ON    THE    DISEASES    OF    INFANTS. 

CASE  XXII. — Henriette  Felicit,  aged  six  weeks,  pale  and  much 
reduced,  had  ah-eady  been  twice  in  the  infirmary  since  her  birth,  for 
a  diarrhoea  of  very  Hquid  discharges,  accompanied  with  tension  of 
the  abdomen,  together  with  vomiting  immediately  after  having  taken 
drink.  She  entered  the  infirmary,  for  the  third  time,  on  the  11th  of 
July,  with  the  following  symptoms  :  general  paleness,  slight  tension 
of  the  abdomen,  which  yet  possessed  some  flexibility ;  cry,  feeble 
but  perfect,  with  vomiting  of  the  drinks.  (Gumed  rice-water,  cata- 
plasm to  the  abdomen,  milk  and  water.)  On  the  15th,  the  face  be- 
came livid,  the  child  refused  drinks,  or  drank  but  little ;  afterwards 
cried  when  an  attempt  was  made  to  put  the  spoon  in  the  mouth  to 
compel  her  to  swallow.  The  milk  was  vomited,  almost  as  soon  as  it 
was  given  her  to  drink,  and  without  any  effort ;  the  diarrhoea  con- 
tinued. From  the  15th  to  the  17th,  these  symptoms  continued,  the 
paleness  increased,  and  she  soon  fell  into  a  state  of  marasmus.  On 
the  ISth,  the  face  became  pinched,  forehead  wrinkled,  cry  very 
feeble,  skin  cold,  and  the  pulse  scarcely  perceptible.  She  died  during 
the  night.  On  making  a  post  mortem  examination  on  the  next  day, 
the  mouth  was  found  pale,  the  pharynx  injected,  the  oesophagus  of  a 
vivid  red  at  the  upper  third,  on  a  level  with  which,  the  epithelium  was 
entirely  destroyed.  The  remainder  of  this  canal  presented  nothing 
more  than  a  number  of  red  striae. 

The  mucous  membrane  of  the  stomach  was  of  an  ash  color,  and  the 
mucus  which  covered  it,  thick  and  very  adherent ;  at  the  termina- 
tion of  the  ileon  there  were  found  eight  slate-colored  tumefied  follicu- 
lar patches.  The  left  lung  was  healthy,  the  right  engorged ;  the 
foetal  openings  were  partially  obliterated ;  the  brain  was  perfectly 
healthy. 

This  child  succumbed  to  oesophagitis,  and  chronic  gastro- 
enteritis, the  probable  cause  of  the  diarrhoea,  and  for  which  she 
had  been  so  frequently  sent  to  the  infirmary. 

The  destruction  of  the  epithelium,  and  the  redness  of  the  upper 
third  of  the  oesophagus,  should  be  noted,  and,  above  all,  the 
quickness,  frequency,  and  obstinacy  of  the  vomiting,  and  undi- 
gested state  of  the  substances  vomited.  The  child  rejected  the 
milk  almost  as  soon  as  it  was  taken,  and  in  the  same  condition 
as  when  taken  ;   this  is  a  circumstance  worthy  of  remark. 

CASE  XXTII.— Sophie  Taillau,    a   small  child,  aged  five  days. 


ON    THE    DISEASES    OF    INFANTS.  227 

affected  with  qedema  of  the  lower  extremities,  and  a  rigidity  of  their 
articulations,  entered  the  infirmary  on  the  19th  of  May.  Her  cry 
was  laborious  and  painful ;  the  forehead  much,  wrinkled  ;  there  was 
no  diarrhoea,  but  she  vomited  promptly  every  thing  she  took ;  the 
sweetened  water  given  her  was  rejected,  sometimes  accompanied 
with  albuminous  flakes,  and  sometimes  mixed  with  yellow  matters. 
The  skin  was  cold,  the  pulsations  of  the  heart  irregular  and  obscure. 
This  child,  nourished  only  by  a  small  quantity  of  sweetened  water, 
and  milk  and  water,  remained  for  three  days  in  the  same  condition, 
vomiting  every  thing  that  was  given,  together  with  a  large  quantity 
of  yellow  and  inodorous  matters.     She  died  on  the  twenty-second. 

Upon  a  post  mortem  examination  of  the  body,  the  tongue  was 
found  covered  with  a  coat  of  mucus,  strongly  adherent ;  the  pharynx 
very  much  injected  ;  the  glottis  infiltrated  and  red  ;  all  along  the 
oesophagus  the  epithelium  was  raised  in  large  shreds,  and  mixed  with 
a  yellow  matter,  resembling  that  which  the  child  had  vomited.  The 
oesophageal  mucous  membrane  presented,  at  the  parts  where  the  epi- 
thelium was  destroyed,  a  very  high  carmine  color.  Besides  this, 
there  were  seen,  near  the  termination  of  the  epithelium,  several  black 
striae. 

The  stomach  presented  a  large  number  of  follicular  ulcerations  at 
its  great  curvature.  The  duodenum  exhibited  a  number  of  red  points, 
and  the  termination  of  the  ileon  was  of  a  uniform  bright  red.  The 
large  intestines  were  healthy,  and  the  liver  was  gorged  with  blood. 

The  posterior  border  of  the  two  lungs  was  gorged  with  blood ;  the 
ductus  arteriosus  was  still  open.     The  brain  was  perfectly  healthy. 

Here  we  have  seen,  besides  oesophagitis,  gastritis  characterized 
by  a  number  of  ulcerations,  the  nature  of  which  will  be  con- 
sidered hereafter.  Perhaps  it  is  to  this  complication  that  the 
vomitings  of  the  yellow  matters  which  attended  or  followed  the 
vomiting  of  drinks,  are  to  be  attributed.  The  destruction  of  the 
epithelium  and  the  carmine  hue  of  the  oesophagus  should  also  be 
particularly  noticed. 

CASE  XXIV. — Induration  of  the  cellular  tissue,  ulcer  of  the 
(Esophagus, — Marie  Bertel,  aged  six  days,  entered  the  infirmary  on 
the  2d  of  May.  She  possessed  a  strong  constitution  ;  the  integu- 
ments were  vermilion  ;  limbs  oedematous  and  hard  ;  the  cry  sufl^o- 
cating  ;  face  without  much  expression,  indicating  occasionally,  how- 
ever, the  presence  of  pain.     On  the  third,  a  great  redness  appeared 


228  ON   THE    DISEASES    OF    INFANTS. 

about  the  arms,  together  with  an  abundant  diarrhoea  of  a  green  color ; 
almost  constant  vomiting  of  glairy  matter,  and  frequent  regurgita- 
tions after  drinking.  The  chest  resounded  obscurely  on  the  right 
side ;  the  pulsations  of  the  heart  were  very  obscure  and  scarcely 
evident,  even  with  the  assistance  of  the  stethoscope ;  the  skin  was 
cold.  The  child  rested  in  the  cradle  as  if  without  life.  (Gummed 
rice-water,  sweetened  decoction  of  iilia,  dry  and  warm  frictions  to 
the  limbs.)  In  this  condition  the  child  remained  until  the  fourth,  but  it 
was  observed  that  she  vomited  a  green  liquid  in  great  abundance. 
Finally,  she  died  at  night,  after  having  had,  for  three  days,  an  exist- 
ence possessing  more  the  resemblance  of  a  slow  dissolution  than  of 
life. 

Post  mortem  examination. — Limbs  stout ;  integuments  still  much 
colored.  The  digestive  apparatus  presented  the  following  appear- 
ances :  a  slight  congestion  at  the  base  of  the  tongue ;  a  bright  red- 
ness of  the  pharynx;  a  well-marked  injection  of  the  upper  part  of  the 
oesophagus,  with  a  longitudinal  ulceration  at  its  inferior  extremity, 
six  lines  long  and  four  broad,  the  bottom  of  which  was  yellow,  the 
borders  thick  and  red,  as  if  bloody  ;  the  mucous  membrane  was  de- 
stroyed in  the  centre  of  this  solution  of  continuity,  the  bottom  of 
which  was  formed  by  the  cellular  membrane  ;  the  stomach  exhibited 
nothing  but  a  slight  injection  ;  the  small  intestines  were  healthy  at 
the  upper  two-thirds ;  near  the  ileo-caecal  region  there  existed  se- 
veral follicular  laminae,  some  of  which  were  slightly  excoriated ; 
some  separate  follicles  were  seen  near  them  ;  the  ileo-caecal  valve 
was  red  and  slightly  tumefied.  The  internal  membrane  of  the  large 
intestines  was  very  red,  considerably  wrinkled,  tumefied,  and  very 
friable.  This  membrane  was  covered  witti  a  green  mucus,  closely 
adherent. 

The  respiratory  apparatus  was  the  seat  of  several  important  le- 
sions ;  the  glottis  was  of  a  bright  red,  and  much  tumefied ;  the  ven- 
tricles of  the  larynx  were  filled  with  thick  mucus  ;  the  trachea  and 
bronchiae  were  covered  with  red  striae.  The  greater  part  of  the  right 
lung  was  hepatized. 

The  heart,  large  vessels,  and  the  brain,  were  filled  with  blood. 

Among  all  the  lesions  with  which  this  child  was  affected,  we 
should  note  particularly  the  remarkable  ulceration  of  the  OBsopha- 
gus,  and  the  obstinate  vomiting,  although  there  existed  no  gas- 
tritis ;  for  we  can  hardly  consider  as  inflammation  of  the  stomach 
the  slight  injection  of  that  organ.   The  suffocated  cry  ought  also 


ON  THE    DISEASES   OP    INFANTS.  229 

to  be  noted,  occurring  as  coincident  with  an  active  inflamma- 
tion of  the  glottis,  which  was,  as  it  were,  obstructed.  The  ab- 
sence of  all  febrile  reaction,  notwithstanding  the  multiplied  in- 
flammation of  all  the  organs  at  once,  ought  particularly  to  be  re- 
marked. 

We  have  thus  far  seen  oesophagitis  without  alteration  of  the 
secretions.  The  following  cases  will  furnish  us  with  instances 
of  oesophagitis  complicated  with  muguet. 

CASE  XXV. — Muguet  of  the  (Esophagus. — Andre  Tallois,  aged 
one  month,  was  affected  for  fifteen  days  after  birth  with  a  palpebral 
ophthalmia,  and  distinct  muguet,  confined  in  appearance  to  the  buc- 
cal membrane.  On  the  19th  of  January,  the  nurse  having  charge  of 
this  child,  brought  him  to  the  infirmary,  and  mentioned  that  he  had 
vomited  his  drinks  very  frequently,  and  was  daily  becoming  emaciat- 
ed. He  was  indeed  pale  and  thin ;  the  inferior  extremities  were  in- 
filtrated ;  the  cry  was  very  feeble,  and  the  pulse  slow  and  small,  and 
beat  from  sixty  to  sixty-five.  {Sweetened  gum-water ,  removal  from 
the  breast,  milk  and  water.)  On  the  20th  of  January,  the  infiltra- 
tion of  the  limbs  was  partially  dissipated ;  the  child  cried  a  little ; 
did  not  appear  to  suflfer  much,  but  vomited  almost  every  thing  that 
was  given  to  drink.  (Same  treatment.)  On  the  25th  of  January, 
the  same  general  state  ;  continuation  of  vomiting.  This  state  con- 
tinued without  change  until  the  2d  of  February,  when  diarrhoea  was 
added  to  the  foregoing  symptoms.  (Gummed  rice-water,  milk  and  wa- 
ter.)  From  the  5th  to  the  10th  of  February,  the  marasmus  made  great 
progress  ;  the  cheeks  became  hollow ;  the  forehead  was  furrowed  with 
wrinkles  ;  the  cry,  by  its  smallness,  indicated  the  extreme  feebleness 
of  the  patient,  and  the  heart  beat  with  so  little  force  that  a  kind  of 
trembling  was  heard,  upon  auscultation,  instead  of  the  true  pulsa- 
tions. Upon  raising  the  child,  or  changing  his  place  in  the  cradle, 
the  least  movement  would  cause  a  regurgitation  of  milky  fluid,  some- 
times mixed  with  white,  pasty,  grumous  matter.  Death  terminated 
this  extreme  languor  on  the  night  of  the  10th  of  February. 

The  body  was  examined  on  the  following  day ;  there  was  found  a 
general  discoloration  of  the  whole  exterior,  and  a  complete  maras- 
mus ;  every  part  of  the  body  appeared,  as  it  were,  exsanguined ;  the 
base  of  the  tongue  was  covered  with  thick  mucus ;  the  raucous 
membrane  of  the  mouth  was  very  pale ;  the  oesophagus  exhibited 
here  and  there  irregular  patches  of  a  bright  red,  and  in  certain  points 


230  ON  THE    DISEASES   OP   INFANTS. 

a  complete  destruction  of  the  epithelium.  There  was  besides  ii*  al- 
most the  entire  extent  of  this  membranous  canal,  a  considerable  num- 
ber of  points  of  muguet,  the  whiteness  of  which  appeared  in  strong 
contrast  with  the  intense  redness  of  the  oesophagus.  This  muguet 
ceased  at  the  epithelium. 

The  stomach  was  perfectly  healthy  ;  the  small  intestines,  distend- 
ed with  gas,  exhibited  at  the  end  of  the  ileon  some  red  patches,  and 
the  mucous  membrane  had  already  begun  to  soften  ;  the  membrane 
of  the  large  intestines  was  red,  wrinkled,  and  tumefied ;  the  lungs 
crepitated  in  the  greatest  part  of  their  extent ;  the  right  lung  alone 
was  hepatized  at  a  very  circumscribed  point ;  the  foetal  openings 
were  obliterated  ;  the  brain  was  perfectly  healthy. 

I  selected  this  case  because  the  chronic  inflammation  was  the 
predominating  disease,  and  because  the  symptoms  which  this 
child  presented  during  life  had  been  observed  with  particular  at 
tention. 

Now,  on  the  one  hand,  the  obstinate  vomiting,  rapid  decay, 
and  progress  of  the  marasmus,  which  increased  until  death, 
must  be  noted  ;  and  on  the  other,  the  healthy  condition  of  the 
stomach,  and  the  violent  inflammation  of  the  oesophagus  covered 
with  muguet.  So  that  we  are  naturally  led  to  establish  between 
the  obstinacy  and  frequency  of  vomiting,  and  the  disorganization 
of  the  oesophagus,  a  relation  so  intimate,  that  we  cannot  regard 
the  one  in  any  other  light  than  as  the  effect  of  the  other.  But  we 
must  not  generalize,  but  still  pursue  the  examination  of  particu- 
lar facts. 

CASE  X.X.'Vl.—Mnguet  of  the  oesophagus. — Alexandrine  Rebet, 
aged  fourteen  days,  entered  the  infirmary  on  the  25th  of  June.  She 
was  of  a  feeble  constitution;  had  neither  vomiting  nor  diarrhoea;  the 
buccal  membrane  was  very  red ;  there  existed  some  points  of  mu- 
guet on  the  edges  of  the  tongue  ;  the  whole  surface  of  the  body  was 
slightly  jaundiced.  (Gummed  barley-water,  emollient  gargle,  ab- 
stinence from  the  breast,  milk  and  water.)  On  the  twenty-sixth, 
a  diarrhoea  supervened,  consisting  of  yellow  fluid.  The  child  also 
vomited  yellow  matters.  The  face  was  much  altered,  and  it  became 
at  times  the  seat  of  contractions,  which  appeared  to  indicate  tran- 
sient pain.  The  parts  surrounding  the  arms  were  very  red  ;  the 
limbs  were  cold  ;  the  pulse  extremely  small  and   frequent ;  the  cry 


ON   THE    DISEASES    OP    INFANTS.  231 

was  feeble,  without  being  husky  or  sulTocating.  (Same  treatment.) 
On  the  twenty-eighth,  the  mucous  membrane  of  the  mouth  was  of  a 
more  intense  red  ;  the  muguet  extended  by  patches ;  the  diarrhoea 
continued  ;  the  discharges  by  vomiting  very  abundant ;  the  matters 
discharged  were  less  yellow ;  the  jaundice  had  disappeared ;  the 
child  began  to  be  emaciated.  On  the  twenty-ninth  and  thirtieth,  the 
same  state  continued.  On  the  2d  of  July,  the  diarrhoea  stopped,  but 
the  vomiting  increased  ;  the  child  retained  nothing  that  was  given  to 
her,  and  she  died  in  the  afternoon. 

The  post  mortem  examination  was  made  on  the  next  day  ;  the 
body  was  partially  reduced  to  a  state  of  marasmus ;  the  tongue  and 
arch  of  the  palate  were  covered  with  a  very  thick  coating  of  muguet; 
beneath  which  the  epithelium  remained  healthy;  for  upon  rais- 
ing the  muguet,  the  epithelium  was  found  adherent  to  the  raucous 
membrane.  The  stomach  and  small  intestines  were  found  perfectly 
healthy ;  the  internal  membrane  of  the  large  intestines  was  soft  and 
tumefied,  but  without  redness  ;  the  respiratory  and  circulatory  sys- 
tems exhibited  no  alteration ;  the  brain  was  healthy. 

In  the  last  two  cases,  we  have  seen  OBsophagitis,  accompanied 
by  an  altered  secretion,  following  stomatitis  with  muguet ;  we 
have  also  seen  obstinate  vomiting  while  the  stomach  was 
healthy.  This  symptom  particularly  deserves  our  attention. 
Before,  however,  endeavoring  to  ascertain  its  value,  let  us  con- 
tinue our  examination  of  the  lesions  of  the  oesophagus,  and  the 
symptoms  of  these  lesions. 

The  prolonged  inflammation  of  an  organ  sometimes  produces 
gangrene  ;  that  of  the  oesophagus  is  rare  ;  yet  it  is  sometimes 
met  with  in  young  infants,  as  will  be  seen  by  the  following  case. 

CASE  XXVII. — Gangrene  of  the  (Esophagus. — Josephine  Char 
ville,  aged  sixteen  months,  was  affected  with  a  curvature  of  the  spine 
from  an  affection  of  the  middle  portion  of  the  dorsal  region  of  the 
vertebral  column.  She  was  pale  and  thin,  but  did  not,  by  her  cries 
nor  by  any  expression  of  the  face,  give  any  evidence  of  pain  in  any 
part  of  her  body.  She  had  been  weaned  for  some  months  ;  and  was 
shortly  afterwards  affected  with  a  mild  attack  of  measles,  which  was 
followed  by  an  eruption  upon  the  lips,  consisting  at  first  of  small 
transparent  vesicles,  afterwards  replaced  by  excoriations  covered 
with  yellow  scabs.     (Herpes  lahialis.)     It  was  for  this  affection  that 


232  ON    THE    DISEASES    OF    INFANTS. 

she  entered  the  infirmary  on  the  6th  of  April,  presenting  the  follow- 
ing symptoms. 

Frequent  vomiting,  particularly  after  having  eaten  ;  acid  eructa- 
tions ;  pulse  slow  and  small ;  general  paleness.  On  the  10th  of 
April,  the  scabs  on  the  lips  dried  and  fell,  and  no  new  ones  were  af- 
terwards formed.  Great  aversion  to  food,  in  a  continual  state  of 
faintness,  without  complaints,  crying,  or  restlessness.  The  servants 
spoke  of  the  continual  tranquillity  of  this  child.  Alvine  evacuations 
natural ;  skin  hot ;  pulse  slow,  (sixty  pulsations.)  On  the  twelfth 
of  April,  the  face  became  infiltrated ;  the  limbs  underwent  a  rapid 
shrinking;  the  child  vomited  less  frequently  the  small  quantity  of 
milk  and  water  given  her,  and  which  was  the  only  treatment  pre- 
scribed. On  the  13th  of  April,  there  was  an  abundant  diarrhoea, 
with  tension  of  the  abdomen  ;  infiltration  of  the  face  ;  general  sink- 
ing ;  eructations  without  vomiting  ;  the  pulse  was  always  small  and 
frequent,  (ninety  pulsations ;)  the  marasmus  made  great  progress, 
the  child  remaining  still  silent  and  prostrated ;  she  cried  but  little, 
and  did  not  appear  to  suffer.  On  the  15th  of  April,  the  same  state ; 
last  stage  of  marasmus ;  extreme  paleness  ;  diarrhoea ;  some  vomit- 
ing of  mucus,  mixed  with  white  flakes.  On  the  seventeenth,  there 
was  nothing  remarkable  but  the  progress  of  the  emaciation.  The 
discharges  from  the  bowels  were  liquid  and  yellow,  and  the  abdomen 
continued  tumefied.  Hitherto  the  child  had  taken  nothing  but  rice- 
water  and  a  little  milk  and  water.  From  the  seventeenth  to  the 
twentieth,  she  remained  depressed,  continually  becoming  daily  more 
emaciated.  She  died  on  the  night  of  the  twentieth,  without  having 
presented  any  symptoms  more  violent  than  those  just  described. 

The  post  mortem  examination  was  made  on  the  following  day. 
The  exterior  of  the  body  exhibited  a  general  discoloration  and  com- 
plete marasmus.  The  mouth  was  healthy,  but  at  the  posterior  sur- 
face of  the  pillars  of  the  velum,  and  on  the  sides  of  the  glottis,  there 
appeared  some  small,  soft,  gray  patches,  surrounded  by  a  red  circle. 
The  same  appeared  in  the  whole  length  of  the  oesophagus,  the  mu- 
cous membrane  of  which  was  reduced  to  large  irregular  eschars  of  the 
color  of  soot,  leaving  between  them  intervals  of  deep,  bright  red  excori- 
ations, which  crossed  almost  the  whole  thickness  of  the  oesophageal 
canal.  The  epithelium,  destroyed  in  almost  all  the  length  of  the  oeso- 
phagus, did  not  consist,  in  the  few  points  that  were  left,  of  any  thing 
more  than  small  irregular  shreds  rolled  together.  The  oesophagus 
diftused  a  very  evident  gangrenous  odor.  A  few  red  striae  were 
found  in  the  stomach;  there  existed  a  general  discoloration   of  the 


ON   THE    DISEASES    OP    INFANTS.  233 

mucous  membrane  of  the  small  intestines ;  but  that  of  the  large  in- 
testines was  thick,  red,  friable,  and  covered  with  a  very  abundant 
mucus. 

The  lungs  were  perfectly  healthy  ;  the  foetal  openings  were  obli- 
terated ;  the  cerebral  pulp  was  healthy,  but  the  lateral  ventricles 
liontained  a  little  more  serosity  than  ordinary. 

It  was  very  difficult  to  make  a  diagnosis  of  oesophagitis  pro- 
ceeding to  the  extent  of  this  case,  from  the  small  number  of 
symptoms  and  the  very  obscure  condition  of  this  child  during 
life :  so  that  we  were  much  surprised  to  find,  upon  opening  the 
body,  so  great  a  disorganization  of  the  oesophageal  canal.  Yet 
the  vomitings,  however  rare  they  had  been,  and  the  frequent 
eructations  ought  to  be  considered  as  a  possible  evidence  of  oeso- 
phagitis. The  little  pain  experienced  by  this  child,  the  absence 
of  all  febrile  reaction,  although  at  a  considerably  advanced  age, 
appeared  to  show  that  the  disease  was  seated  in  an  organ  mor- 
tally affected  from  the  commencement  of  the  inflammation. 

The  principal  alterations  of  oesophagitis  having  passed  in 
review,  we  will  add  to  what  has  been  stated,  that  the  epithelium 
is  often  found  raised  in  some  points  like  an  exfoliation,  without 
any  trace  of  inflammation  accompanying  it ;  that  the  denuded 
points  of  the  mucous  membrane  of  the  oesophagus  have  a  yellow 
tint  in  those  points  destitute  of  the  epithelium,  and  that  nothing 
is  more  common  than  to  see  the  whole  interior  of  this  canal 
covered  and  colored  with  matters  which  have  flowed  from  the 
stomach  towards  the  mouth  either  before  or  after  death.  Care 
should  be  taken  not  to  mistake  these  various  alterations  of 
color  for  traces  of  inflammation,  and  to  the  existence  of  which 
much  importance  must  not  be  attached.  I  once  found  a  gelati- 
nous softening  at  the  inferior  extremity  of  the  oesophagus,  at  its 
lower  third,  which  appeared  to  be  on  the  point  of  being  perforat- 
ed. I  will  refer  to  this  case  when  treating  of  intestinal  hemor- 
rhages, a  disease  with  which  the  child  was  at  the  same  time  af- 
fected. 

If  the  symptoms  which  have  been  observed  in  children  affect- 
ed with  oesophagitis  be  now  recapitulated,  we  shall  see  the  most 
frequent  is  vomiting ;  that  this  vomiting  exists  without  gastritis  ; 
that  its  proper  characteristic  is,  that  it  occurs  immediately  after 


234  ON   THE    DISEASES   OP    INFANTS, 

deglutition,  or  a  short  tim^  after  the  ingestion  of  drinks  or  ali- 
ments. The  niatters  vomited  are  scarcely  altered,  and  still  exhi- 
bit the  characters  of  the  drinks  taken  by  the  child.  As  to  the 
other  symptoms,  such  as  the  refusal  of  the  breast,  aversion  to 
drinks,  deglutition  of  half  solid  aliments,  with  greater  ease  than 
those  that  are  altogether  liquid,  progressive  feebleness,  and  maras-^ 
mus — they  are  common  to  all  other  diseases  of  the  digestive  tube, 
and  only  merit  a  secondary  consideration. 

I  shall  now  be  able  to  trace  the  history  of  this  disease  in  new- 
born children,  as  it  has  been  made  clear  by  this  statement  of 
facts. 

Causes. — The  habitual  congestion  of  the  oesophagus  of  young 
infants  is  properly  one  of  the  predisposing  causes  of  oesophagitisy 
which  in  them  is  really  of  much  more  frequent  occurrence  than 
in  adults.  If  authors  on  the  diseases  of  children  have  not  point- 
ed out  this  frequency,  it  is,  without  doubt,  because  they  have  ne- 
glected to  enlighten  themselves  on  this  subject,  by  the  examina- 
tion of  the  bodies  after  death,  and  particularly  the  pharynx  and 
oesophagus.  The  occasional  causes  depend  on  the  nature  and 
temperature  of  the  drinks  which  are  given  to  children.  If,  when 
they  are  fed  with  the  spoon,  wine,  broth,  or  milk,  too  hot  be  given 
them,  under  the  notion  of  imparting  strength,  we  can  easily  con- 
ceive that  these  drinks  would  very  seriously  irritate  an  organ, 
the  sanguineous  congestion  of  which  will  dispose  it  to  become 
disorganized. 

Symptoms. — A  child  affected  with  oesophagitis  vomits  imme- 
diately the  milk  given  it  to  drink,  before  digestion  has  had  time 
to  produce  any  change  in  it.  It  refuses  the  breast  *,  nutrition  is 
not  carried  on;  it  becomes  emaciated  without  exhibiting  the 
symptoms  which  usually  belong  to  phlegmasia  of  other  parts  of 
the  digestive  organs  ;  sometimes  it  vomits,  besides  drinks,  other 
matters  which  have  flowed  from  the  stomach  ;  but  such  a  case  is 
more  rare,  at  least  if  there  be  not  at  the  same  time  gastro-enteri- 
tis.  There  exists  probably  greater  or  less  pain  in  the  whole 
track  of  the  oesophagus  ;  but  as  the  child  is  unable  to  indicate 
the  presence  of  it,  we  cannot,  by  any  exterior  sign,  be  apprised 
of  its  existence.  Yet  the  attempt  might  be  made  by  endeavoring 
to  excite  the  cries  of  the  child  by  pressing  the  throat  in  the  di- 
rection of  the  oesophagus. 


ON   THE    DISEASES    OF    INFANTS.  235 

Varieties  of  oesophagitis, — The  alteration  which  accompanies 
OBSophagitis  is  not  always  the  same  ;  there  may  be  simple  or 
erythematic  inflammation,  inflammation  with  altered  secretion 
or  gangrenous  inflammation. 

As  oesophagitis  almost  always  follows  stomatitis,  and  as  the 
latter  exhibits  to  the  sight  the  anatomical  characters  which  dis- 
tinguish it,  we  are  led  to  believe  that  a  child  will  be  afiected  with 
OBSophagitis,  with  aphthae,  or  muguet,  when  the  symptoms  which 
we  have  pointed  out  follow  stomatitis  with  aphthae  or  muguet. 
It  appears  to  me  very  diflicult  to  be  able  to  distinguish  the  exist- 
ence of  ulcers  and  of  gangrene  of  the  oesophagus,  at  least  when 
the  child  does  not  vomit  the  shreds  resulting  from  the  disorgani- 
zation produced  in  the  oesophagus  by  the  disease.  Experience 
and  ulterior  observations  may  put  it  in  our  power  to  ascertain 
by  the  symptoms  the  existence  of  alterations  in  the  tissue. 

Treatment. — It  will,  in  the  first  place,  be  necessary  to  abstain 
from  giving  to  the  young  infant  stimulating  or  hot  drinks.  It 
should  never  be  allowed  to  take  any  drink  but  at  the  temperature 
of  the  breast  milk.  When  it  is  perceived  that  the  child  vomits 
♦quickly  after  having  taken  the  drink,  a  small  quantity  should 
then  be  given  at  a  time,  and  a  cataplasm  applied  to  the  throat, 
particularly  when  the  peculiar  symptoms  of  oesophagitis  appear 
after  stomatitis.  A  slight  irritation  in  the  digestive  tube  at  a  part 
far  removed  from  the  disease,  should  be  established  either  by 
means  of  a  few  grains  of  calomel,  or  by  the  administration  of 
small  injections  of  sweetened  milk;  and  the  strength  of  the  pa- 
tient supported  by  the  injection  of  a  mixture  of  milk  and  broth, 
or  of  milk  holding  in  suspension  a  small  quantity  of  arrow-root 
or  potato  starch. 

I  have  not  noticed  any  nervous  aflections  of  the  oesophagus  in 
young  infants ;  it  is  nevertheless  possible  that  their  vomitings  may 
sometimes  be  owing  to  a  spasmodic  contraction  of  the  tube  ;  but 
I  am  unable  to  support  this  assertion  by  any  fact,  and  I  must  be 
content  to  speak  with  all  the  doubt  appertaining  to  a  simple  sug- 
gestion. 

I  cannot  terminate  this  chapter  without  speaking  of  the  remark- 
able coincidence  between  inflammation  of  the  oesophagus  and 
vomiting — a  coincidence  to  which  authors  have  not  fixed  their 
attention.    In  almost  all  treatises  on  diseases  of  children,  there  is 


236  ON   THE    DISEASES    OP    INFANTS. 

a  long  chapter  devoted  to  vomiting  ;  but  no  one  has  referred  to 
oesophagitis  as  one  of  the  causes  of  this  morbid  phenomenon. 
Yet  the  cases  which  I  have  reported  sufficiently  prove  that  vom- 
iting is  a  common  symptom  of  this  disease,  for  I  have  chosen 
only  those  cases  where  the  stomach  was  not  involved,  that  noth- 
ing may  complicate  the  study  of  the  analysis  of  its  symptoms. 

If  reference  be  made  to  the  experiments  of  Beclard,  established 
for  the  purpose  of  elucidating  the  contradictions  between  the  ex- 
periments of  MM.  Magendie  and  Maingault  upon  vomiting,  it 
will  be  seen  that  this  learned  anatomist  has  ascertained  that  the 
oesophagus  took  an  active  part  in  vomiting ;  that  the  stomach, 
compressed  by  the  abdominal  muscles  and  diaphragm,  was  also 
drawn  up  by  the  oesophagus,  which,  receiving  the  matters  vomit- 
ed, itself  contracted  upon  them  and  expelled  them  by  its  own 
proper  action.  The  facts  which  I  have  recorded,  go  to  the  sup- 
port of  these  conclusions.  Indeed  if  we  suppose  the  oesophagus 
inflamed,  we  can  conceive  that  it  is  without  cessation  stimulated 
by  the  irritation  thus  produced,  and  that  it  exercises  frequent 
contraction,  capable  of  provoking  the  ejection  of  matters  contain- 
ed in  the  stomach.  It  is  perhaps  to  the  habitual  congestion  of 
the  oesophagus  that  the  facility  with  which  young  infants  vomit 
their  drinks  is  owing.  I  have  entered  upon  this  physiological 
digression  because  it  appears  to  me  that  all  the  parts  of  medical 
science  are  closely  connected,  and  that  we  should  always  be 
ready  to  avail  ourselves  of  an  opportunity  of  assisting  in  the  dif- 
fusion of  that  light  which  they  are  able  to  shed  upon  one  another. 

As  vomiting  is  a  symptom  common  to  a  great  number  of  dis- 
eases, I  shall  not  attempt  to  establish  its  value  with  reference  to 
symptomatology,  until  I  shall  have  caused  all  the  circumstances 
under  which  it  may  be  observed,  to  pass  in  review. 

DISEASES   OF   THE    SUB-DIAPHRAGMATIC    PORTION   OP    THE 
DIGESTIVE   TUBE. 

This  portion  of  the  digestive  canal,  I  divide  into  two  parts — 
the  stomach,  and  the  intestines. 


on  the  diseases  op  infants.  237 

Section!. 

diseases  of  the  stomach. 

Anomalies  and  malformations. — The  stomach  originally 
consists  of  a  long  tube,  somewhat  larger  than  the  rest  of  the  di- 
gestive tube,  situated  vertically,  until  the  great  tuberosity,  which, 
at  first,  is  scarcely  apparent,  begins  to  acquire  a  greater  volume, 
thus  changing  a  little  the  primitive  form  and  direction  of  the  or- 
gan. The  oesophageal  opening  is  of  considerable  dimensions  du- 
ring the  whole  time  of  gestation ;  the  pylorus  begins  to  narrow 
about  the  fourth  month  ;  and  from  the  sixth  month  until  birth, 
the  valve  surrounding  this  orifice  becomes  more  apparent ;  and  at 
the  time  of  birth  it  is  generally  perfect,  although  the  contrary  as- 
sertion has  been  made. 

The  stomach  exhibits  anomalies,  particularly  with  reference 
to  its  situation.  There  exist  several  cases  of  a  total  inversion  of 
the  abdominal  organs  ;  and  the  stomach  often  partakes  of  this 
derangement.  M.  Baron  has  met  with  several  instances  at  the 
Hospice  des  Enfans  Trouves.  The  anomalies  of  form  are  also  fre- 
quent ;  they  are,  however,  but  slightly  developed :  such  as  the 
strictures  which  appear  in  its  length,  and  which  divide  it,  as  it  were, 
into  two  or  three  parts  ;  a  disposition  analogous  to  that  which  is 
observed  in  certain  animals.  It  is  very  rare  to  see  no  communica- 
tion between  the  stomach  and  duodenum,  or  to  see  but  a  very 
narrow  Opening  into  this  intestine  ;  yet  Fleischmann,  as  quoted 
by  Meckel,  found  a  considerable  stricture  complicated  with  the 
absence  of  the  pyloric  valve.* 

The  entire  absence  of  this  organ  is  only  observed  in  those 
children  deprived,  at  the  same  time,  of  many  of  their  other  organs. 

As  to  hernias  of  the  stomach,  they  are  possible  under  very  pe- 
culiar circumstances,  of  which  I  shall  speak  when  treating  of  ab- 
dominal hernias  in  general. 

DISEASES    OF    THE    STOMACH    DEVELOPED    DURING    INTRA- 
UTERINE   LIFE. 

In  order  to  be  well  assured  of  the  pathological  condition 
of  the  stomach  in  a  young  infant,  its   condition    in    health 

*  Anat  gSner.  descript,  et  patholog.  t.  3,  p.  430. 


238  ON   THE   DISEASES   OF   INFANTS. 

must  first  be  known.  Now,  from  the  examination  of  the 
stomach  in  several  embryos  and  foetuses,  it  appears  that  the 
internal  surface  of  this  organ  is  of  a  light  red  color,  more 
or  less  marked  ;  that  the  internal  membrane  soon  shows  the  ex- 
istence of  villi ;  that  they  are  more  evident  than  in  adults  ;  and 
that  this  internal  membrane  towards  the  fourth  or  fifth  month, 
less  adherent  than  the  other  membranes,  may  be  separated  from 
them  with  great  ease.  Meckel  observes  that  it  is  very  thick  to- 
wards the  fourth  or  fifth  month  of  pregnancy.  At  first  sight,  it 
might  be  thought  to  be  the  case,  but  it  should  be  remembered 
that  the  muscular  coat  is  almost  always  raised  with  it ;  and  the 
subjacent  cellular  membrane  which,  not  being  quite  so  distinct, 
is  added  to  the  mucous  membrane,  adheres  to  it,  and  is  raised  at 
the  same  time.  At  birth,  the  stomach  of  an  infant  is  but  little  di- 
lated. It  encloses  a  quantity  of  ropy  mucus,  with  which  there  is 
sometimes  mixed  some  small  grumous  particles,  apparently  com- 
posed of  concrete  mucus.  In  still-born  children  there  is  found  a 
layer  of  mucus,  more  or  less  thick,  adhering  to  the  surface  of 
this  organ.  Upon  raising  it  with  the  nail  or  the  back  of  the 
scalpel,  the  internal  membrane  is  seen  beneath  this  layer  perfect- 
ly healthy.  This  mucus  disappears  after  a  few  days  ;  and  this 
is  doubtless  what  several  authors,  and  Capuron  in  particular, 
means  by  the  name  of  saburra,  the  removal  of  which  it  was  ne- 
cessary to  effect  immediately  after  birth.  We  shall  see  that  the 
same  thing  exists  in  the  intestinal  tube ;  when  we  shall  be  able 
to  appreciate  more  fiiUy  the  nature  of  the  advice  given  for  the 
expulsion  of  this  substance. 

The  color  of  the  contents  of  the  stomach  of  a  new-born  child 
varies  from  that  of  the  white  of  an  egg  to  that  of  porraceous 
biliary  matter.  With  mucus  there  are  also  sometimes  found  red 
or  brown  striee  ;  but  the  various  alterations  are  attributable  to 
causes,  which  we  will  consider  when  we  shall  have  completed 
the  pathology  of  the  stomach. 

Congestions. — Congestions  of  the  stomach  are  of  frequent  oc- 
currence in  young  infants  ;  they  vary  from  a  ramiform  and  ca- 
pillary injection,  to  a  general  violet  tint  of  the  walls  of  this  organ 
In  order  to  obtain  a  satisfactory  reason  for  these  varieties,  the 
kind  of  death  must  always  be  born  in  mind.  As  the  child  gene- 
rally dies  from  asphyxia,  it  is  very  common  to  find  in  one  born 


ON  THE   DISEASES   OF   INFANTS,  239 

dead  a  sanguineous  congestion  of  the  stomach,  corresponding 
with  the  general  plethora  of  the  vessels  of  the  abdomen  in  which 
the  blood  is  generally  found  stagnated.  Nothing  is  more  com- 
mon than  to  find  not  only  the  injection  of  which  I  have  been 
speaking,  but  a  certain  quantity  of  blood  exuded  on  the  surface 
of  the  stomach,  in  children  that  have  died  in  the  womb,  during 
birth,  or  some  hours  after  birth.  We  should  not  be  hasty,  there- 
fore, in  attributing  to  inflammation  these  congenital  congestions, 
if  I  may  be  allowed  so  to  call  them,  and  not  to  lose  sight  of  the 
mechanical  cause  producing  them. 

Inflammations. — But  it  is  not  exclusively  so  in  every  in- 
stance ;  inflammation  may  really  effect  in  the  stomach  of  an  in- 
fant during  its  sojourn  in  the  womb,  and  give  rise  to  disorgani- 
zation too  evident  to  allow  their  nature  to  be  called  in  question. 
Let  us,  however,  cite  the  facts  in  support  of  this  assertion,  which, 
without  them,  can  only  be  regarded  as  conjecture. 

CASE  XXVIII. — Debuire,  a  male,  just  born,  was  exposed  in  the 
Creche  on  the  7th  of  June,  at  8  o'clock  in  the  morning,  and  died  in 
the  evening,  without  having  presented  any  other  symptoms  than 
painful  cries,  an  almost  permanent  contraction  of  the  face,  and  vo- 
miting of  brown  matters.  The  post  mortem  examination  was  made 
the  next  day. 

The  limbs  were  robust,  and  the  exterior  of  the  body  was  in  a  good 
condition ;  the  integuments  were  highly  colored  ;  the  umbilical  cord 
was  a  little  shrunk. 

A  passive  redness  of  a  violet  color  was  found  in  the  pharynx,  la- 
rynx, and  oesophagus.  The  internal  surface  of  the  stomach  exhibit- 
ed several  small  white  follicles,  about  the  size  of  a  millet-seed.  The 
great  tuberosity  was  perforated  with  irregularly  round  ulcers,  result- 
ing evidently  from  the  disorganization  of  the  mucous  follicles,  for 
some  of  them  were  still  partially  ulcerated.  These  ulcers  were 
formed  at  the  expense  of  the  mucous  membrane ;  the  centre  of  each 
was  of  a  bright  yellow,  and  their  borders,  which  were  slightly  tume- 
fied, were  of  a  carmine,  strongly  contrasting  with  the  white  mem- 
brane surrounding  them  ;  the  stomach  contained  a  quantity  of  ropy 
mucus,  mixed  with  thick  flakes  of  the  color  of  bistre,  and  streaks  of 
blood,  the  color  of  which  was  not  altered.  There  existed  a  discolo- 
ration without  softening,  in  the  mucous  membrane  of  the  small  intes- 
tines.    There  were  several  white  follicles  surrounded  by  a  red  circle 


240  ON   THE    DISEASES    OF    INFANTS. 

in  the  cecum ;  but  they  were  not  ulcerated.  Sorne  of  these  follicles 
were  found  in  the  colon,  but  in  general  this  intestine  was  in  a  healthy 
condition. 

The  liver  was  gorged  with  blood  ;  the  bile  in  the  gall-bladder  was 
of  a  porraceous  green  ;  the  lungs  were  gorged  with  blood  ;  the  foetal 
openings  had  already  begun  to  close  ;  the  brain  was  very  much  in- 
jected, and  the  pulp  was  soft;  the  vessels  which. were  traced,  were 
more  in  number,  and  nearer  together,  towards  the  corpora  striata, 
and  spread  in  rays  in  different  parts  of  each  hemisphere. 

This  case  clearly  proves  the  possibility  of  an  inflammation  of 
the  stomach  during  the  sojourn  of  the  infant  in  the  uterus — an 
inflammation,  the  effects  of  which  were  brought  with  the  child 
when  born,  and  which  might  give  rise  to  symptoms  which  ought 
not  to  escape  the  attention  of  the  physician ;  here  it  was  the  fol- 
licular apparatus  that  was  particularly  affected.  Its  disorganiza- 
tion was  less  advanced  in  the  cecum.  It  would  appear  that  the 
development  was  recent,  for  the  child  was  not  in  the  least  degree 
emaciated,  and  the  disease  appears  not  to  have  arrested  the  pro- 
gress of  the  foetal  evolution  ;  it  is  probable  then,  that  it  was  man- 
ifested in.  the  last  days  of  foetal  existence.  The  symptoms  were 
confined  to  the  pinched  appearance  of  the  face,  to  the  painful 
cries,  and  the  vomiting  of  brown  matters.  These  signs  may  be 
common  to  all  the  other  diseases  of  the  digestive  tube  ;  yet  I  will 
here  observe,  that  I  have  almost  always  seen  vomiting  of  brown 
matter  in  cases  of  ulceration  of  the  follicles  of  new-born  children. 
They  appear  to  me  to  have  been  the  result  of  an  alteration  in  the 
blood  exhaled  in  the  stomach,  as  the  red  streaks  mixed  with 
these  matters  sufficiently  attest.  Be  this  as  it  may,  these  symp- 
toms, although  vague,  were  sufficient  to  excite  the  solicitude  of 
the  persons  having  charge  of  this  child. 

M.  Denis  has  observed  these  follicular  ulcerations,  of  which  he 
has  given  instances.  I  shall  have  occasion  to  speak  again  of 
theni  in  the  course  of  this  work. 

CASE  XXIX. — Marie  Arbuison  was  deposited  in  the  Creche  on 
the  13th  of  November,  1826.  She  was  born  pale,  thin,  and  feeble  ; 
as  the  emaciation  was  observed  to  increase  every  day,  she  was  ac- 
cordingly sent  to  the  infirmary  on  the  nineteenth  of  the  same  month 
— that  is  to  say,  six  days  after  birth.     The  inferior  extremities  were 


ON  THE  DISEASES  OP   INFANTS.  241 

(Edematous  and  hard ;  the  body  exhibited  a  general  paleness  ;  the 
mouth  was  dry  ;  the  skin  dry  and  hot  ;  the  pulse  very  small ;  there 
existed  an  abundant  diarrhoea ;  the  cry  was  stifled,  and  could  scarce- 
ly be  heard  ;  the  left  side  of  the  thorax  gave  a  dull  sound  upon  per- 
cussion, where  the  respiratory  murmur  could  not  be  heard.  [Gum- 
med harley-water,  milk  and  water.)  From  the  twentieth  to  the 
twenty-second,  there  was  no  other  symptom  present;  the  child 
vomited  very  rarely,  and  only  a  small  quantity,  of  the  drinks  given ; 
the  cry  became  acute,  short,  and  painful.  On  the  twenty-sixth,  the 
diarrhoea  ceased,  but  it  was  followed  by  abundant  vomiting;  the  child 
was  constantly  afliected  with  dyspnoea ;  the  extremities  were  of  a  vio- 
let color  and  infiltrated.     Death  took  place  on  the  twenty-eighth. 

Upon  examining  the  body,  there  was  found  a  very  intense  redness, 
with  tumefaction  of  the  internal  membrane  of  the  oesophagus,  espe- 
cially at  the  lower  extremity  ;  the  stomach,  which  was  filled  with 
gas,  was  white  in  almost  all  its  extent,  and  its  internal  membrane 
was  of  a  healthy  consistence  ;  but  at  the  pylorus,  and  in  a  portion  of 
the  great  curvature,  there  existed  a  deep,  round  ulcer,  about  two  lines 
in  diameter,  with  reddish-brown,  perpendicular  edges,  and  much 
elevated ;  there  was  no  inflammatory  tumefaction  surrounding  this 
ulcer,  the  bottom  of  which  was  black,  and  was  formed  by  the  serous 
membrane  of  the  organ,  for  the  entire  thickness  of  the  mucous  mem- 
brane was  destroyed.  From  its  form,  and  the  disposition  of  its  edges, 
it  appeared  to  be  a  disorganization  of  a  muciparous  follicle ;  it  re- 
sembled, in  every  respect,  the  chronic  follicular  ulcers  found  in  the 
ileo-csecal  region,  in  certain  cases  of  phthisis.  When  the  exterior 
of  the  stomach  was  observed  in  the  part  corresponding  with  the  ul- 
cer, there  appeared  a  circular  brown  spot,  surrounded  by  some 
branches  of  vessels  slightly  ramified.  The  small  intestines  were 
nealthy  ;  the  colon  was  a  little  tumefied,  and  slightly  injected.  In 
the  left  lung,  there  appeared  to  be  the  commencement  of  hepatiza- 
tion. The  foetal  openings  were  still  free ;  the  brain  presented  noth- 
ing but  a  slight  injection. 

The  ulcer  of  the  stomach,  no  doubt,  existed  at  the  time  of 
birth.  CEsophagitis  supervened  afterwards,  and  to  the  develop- 
ment of  which  must  be  attributed  the  abundance  and  frequen- 
cy of  the  vomiting" ;  this,  together  with  the  pneumonia  charac- 
terized during  life  by  the  distinctive  symptoms  of  this  disease,  were 
doubtless  the  principal  cause  of  the  death  of  this  child  ;  while 
the  debility  and  blanched  condition  of  the  surface  must  be  refer- 

31 


242  ON   THE    DISEASES    OF   INFANTS. 

red  to  the  ulcer  in  the  stomach.  This  indolent  ulcer,  like  many 
other  chronic  affections,  might  perhaps  have  been  cured,  if  the 
other  two  inflammations  had  not  concurred  in  hastening  dissolu- 
tion from  the  commencement. 

Inflammation  of  the  stomach,  in  young  infants,  may  appear 
under  another  form,  and  may  vary  from  a  simple  capfllary  injec- 
tion to  a  disorganization,  analogous  to  those  which  have  just 
been  described.  Without  doubt,  it  will  sometimes  be  difficult  to 
recognise  the  existence  of  this  disease ;  yet  when  the  physician 
sees  any  one  of  the  symptoms  of  gastritis,  which  will  be  given 
below,  he  ought,  without  delay,  to  use  those  means  which  will  be 
pointed  out  for  its  treatment. 

DISEASES    DEVELOPED    IN    THE    STOMACH    AFTER  BIRTH. 

It  is  a  principle  of  some  of  the  most  ancient  philosophers,  espe- 
cially of  Anaxagoras,  that /rom  nothing  comes  nothing y  and  that 
every  effect  supposes  the  existence  of  a  cause.  This  principle, 
applied  to  medical  science,  has  been  recently  illustrated,  with 
much  ability,  by  MM.  Beclard  and  Rostan.*  They  remark, 
with  other  pathologists,  that  a  disturbance  in  the  functions  of  an 
organ,  supposes,  in  every  instance,  an  alteration  in  the  organ. 
Nothing  is  more  true,  and  nothing  more  likely  to  mislead  than 
this  rule  ;  but  it  must  not  be  taken  strictly  according  to  the  letter, 
and  no  false  interpretation  made  of  it,  as  it  will  thereby  lose  its 
importance  and  its  truth, — for  the  functions  of  an  organ  may 
become  disturbed,  without  the  organ  itself  exhibiting  any  sensi- 
ble alteration  in  its  structure ;  yet  the  cause  exists,  and  it  is  the 
duty  of  the  physician  to  search  for  it,  that  the  affection  may  be 
properly  treated.  The  study  of  the  diseases  of  the  stomach  and 
intestines,  in  infants  at  the  breast,  will  demonstrate  to  us  the  truth 
of  this  remark,  and  we  shall  see  the  functions  of  the  stomach 
disturbed  without  any  apparent  lesion  existing  in  that  organ. 
We  might  explain  this  phenomenon,  d  priori,  in  applying  to  the 
infant  the  symptoms  which  arise  from  the  sympathies  existing  in 
adults,  between  the  stomach  and  various  parts  of  the  body ;  but, 
faithful  to  the  plan  which  we  have  marked  out,  we  shall  endea- 
vor  to  seek,  in  the  first  place,  for  the  causes  which  produce 

♦  Beclard,  Anat.  Gen.,  introduction.     Rostan,  Traite  de  diagnostic,  etc. 


ON   THE    DISEASES    OP    INFANTS.  243 

them,  by  the  simple  analysis  of  facts.  In  order  to  examine  this 
subject  in  proper  order,  it  will  be  useful  to  divide  the  diseases  of 
the  stomach  in  infants  into  two  sections,  and  to  consider — 1st,  the 
disturbance  of  the  functions  of  the  organ,  without  sensible  lesioi^ 
of  its  walls  ;  2dly,  the  organic  lesion,  with  or  without  disturbance 
of  the  functions. 

Art.  1. — Gastric  Indigestion. 

Infants  very  often  vomit  the  milk  they  have  taken,  soon  after 
it  has  been  swallowed.  Sometimes  it  returns  unaltered, — at 
other  times  it  is  coagulated  in  masses  of  a  greater  or  less  size. 
Boerhaave,  Van  Swieten,  Rosen,  and  since  them,  Underwood, 
MM.  Capuron,  Gardien,  and  others,  have  spoken  of  this  morbid 
phenomenon,  when  giving  the  history  of  vomiting. 

There  exist  various  degrees  of  disturbance  in  the  functions  of 
the  stomach ;  sometimes  the  child  will  only  be  affected  with  a 
simple  regurgitation,  which  produces  cough  or  hiccup ;  when  a 
large  quantity  of  milk  has  been  taken  at  once,  the  stomach,  con 
siderably  distended,  rejects  the  superfluous  food  it  contains ;  at  other 
times  the  vomiting  is  the  result  of  a  true  indigestion,  for  the  eject- 
ed matters  show,  by  their  form  and  aspect,  that  the  physiological 
action  of  the  stomach  has  not  produced  such  an  alteration  as 
would  allow  of  their  being  absorbed. 

When  a  child  vomits  under  the  circumstances  first  mentioned, 
it  is  easy  to  remove  the  cause ;  and  such  is  the  disposition,  in 
some  infants,  to  vomit,  that  the  slightest  movement  that  is  given 
to  the  body  while  playing  with  them,  or  the  hurried  walk  of  the 
nurse,  will  cause  them  to  discharge  their  drinks,  or  milk  they 
may  have  taken. 

Van  Swieten  and  Rosen  have  remarked,  that  it  "is  very  com- 
mon to  meet  with  milk  coagulated  in  the  stomach,  without  bemg 
digested.  The  authors  just  mentioned  attribute  it  to  the  super- 
abundance of  acid  in  the  stomach.  A  very  evident  acid  smell  is 
often  detected  in  the  mouth  of  a  child ;  like  that,  for  instance, 
which  is  observed  after  an  attack  of  indigestion.  I  found,  in 
fifteen  infants  that  died  with  other  affections  than  those  of  the 
digestive  organs,  the  stomach  fillea  with  coagulated  milk ;  there 
were  but  three  exhibiting  a  slight  injection  of  the  stomach  ;  in 
the  remaining  twelve  the  walls  of  this  organ  were  white  and 


244  ON  THE  DISEASES  OF  INFANTS. 

perfectly  healthy.  I  am  inclined  to  think  that,  this  coagulation 
of  milk  proceeded  from  some  cause  other  than  inflammation. 
Does  this  result  from  the  milk  taken  by  the  child  abounding  in 
caseum,  or  is  it  the  presence  of  acid  in  the  stomach  that  so  quick 
ly  coagulates  this  fluid  ?  Does  this  acid  exist,  in  the  first  place, 
in  the  stomach?  Is  it  the  result  of  the  decomposition  of  the 
milk?  Does  this  indigestion  depend  upon  the  want  of  vital 
activity  and  nervous  action,  which  is  displayed  in  the  stomach 
during  the  operation  of  the  digestive  functions?  These  are 
questions  I  am  unable  to  solve ;  but  whatever  be  the  cause  of  this 
phenomenon,  I  point  it  out  as  the  effect  of  a  true  gastric  indiges- 
tion, without  inflammation  of  the  organ,  and  without  apparent 
lesion  of  its  walls  ;  and  I  wish  particularly  to  direct  the  attention 
of  physicians  to  this  fact,  that  they  may  not  be  led  to  conclude 
that  a  child  is  affected  with  gastritis,  whenever  it  is  unable  to 
digest  the  milk  that  it  has  taken,  or  when  the  milk  is  vomited 
some  time  after,  in  a  coagulated  form.* 

Yet  it  happens  that  the  stomach  being  inflamed,  the  child  can- 
not digest,  and  then  vomits  the  milk  it  has  taken ;  but  the  proper 
signs  of  inflammation  will  enable  us  to  detect  the  existence  of 
inflammation  in  the  stomach,  when  connected  with  this  vomiting, 
and  serve  to  give  us  some  knowledge  of  the  lesion  accompany- 
ing it. 

There  are  still  other  circumstances,  when  the  digestion  is 
found  to  be  altogether  disturbed,  where  the  stomach  not  only 
rejects  what  it  has  taken,  but  also  the  contents  of  the  intestines 
which  flow  towards  it.  The  cause  of  this  may  be  either  a  vio- 
lent inflammation  of  the  OBSophagus,  as  we  have  already  seen,  or 
an  intestinal  phlegmasia,  an  ileus,  or  some  obstruction  in  the  in- 
testinal canal.  When  we  speak  of  each  of  the  diseases  which 
produce  disorders  of  the  digestive  functions,  their  influence  will 

*  J.  L.  Petit  has  pointed  out  the  particular  manner  of  this  regurgitation  of  the  milk  in 
nursing  children.  He  has  reported  a  number  of  experiments  upon  animals,  in  order  to 
overthrow  the  opinion  so  widely  spread,  that  it  is  an  unfavorable  symptom  to  see  a 
child  return  the  milk  soured  or  coagulated.  He  has  undertaken  to  prove  that  this 
double  change  in  the  milk  is,  on  the  contrary,  one  of  the  preliminary  changes  to  which 
the  milk  is  always  submitted,  to  be  thereby  more  easily  digested.  See  his  Obs.  mr  la 
digestion  du  lait  dans  les  enfans,  qui  sont  a  la  Mamelle.  ( Traite  de  Malad.  Clinrug,) 
t.  3,  p.  338. 


ON   THE    DISEASES    OF    INFANTS.  245 

be  duly  examined,  for  it  is  not  derangements  of  the  circulating 
or  cerebo-spinal  apparatuses  alone  that  may  cause  the  gastric  di- 
gestion to  be  disturbed  in  young  infants,  and  cause  their  vomiting. 

Can  infants  at  the  breast  be  affected  with  gastralgia  ?  This  is 
difficult  to  prove,  for  gastralgia  being  characterized  by  pain,  either 
continued  or  remitting,  of  which  the  stomach  is  the  seat,  and  the 
child  not  possessing  the  faculty  of  referring  to  this  pain,  we  are 
without  the  necessary  evidence  of  its  existence.  Nevertheless,  as 
we  observe  in  other  organs  affected  with  nervous  derangements 
analogous  to  those  which  occur  in  the  nerves  of  digestion,  we  can 
suppose  the  existence  of  a  morbid  exaltation  in  the  stomach  of 
young  infants;  and  it  is,  without  doubt,  this  condition  which 
several  pathologists  have  wished  to  designate,  in  speaking  of  the 
excessive  irritability  of  the  stomach,  and  the  spasmodic  vomitings 
of  infants;  but  it  must  be  confessed  that  they  have  expressed 
themselves  very  vaguely  on  this  subject,  and  without  supporting 
their  assertions  by  any  facts,  from  the  impossibility,  doubtless,  of 
collecting  the  necessary  facts  for  its  illustration.  When  Rosen 
speaks  of  vomiting,  arising  from  mental  emotions,  and  particularly 
from  fear  or  from  some  shock,  he  refers,  probably,  to  children  of 
more  advanced  age  than  those  whose  pathology  we  are  studying.* 

Poisoning  has  been  pointed  out  as  one  of  the  causes  capable  of 
disturbing  the  digestion  of  infants,  and  thus  producing  vomiting. 
This  poisoning  may  arise  from  the  ingestion  of  some  injurious 
substance  that  forms  on  the  metallic  articles  that  may  be  given 
to  the  child  to  bite  on,  or  in  the  vessels  in  which  the  drinks  are 
prepared;  but  this  accident  is  very  rare  at  an  age  when  the  child 
is  nourished  by  the  mother's  milk  or  thin  pap. 

The  color  of  the  matters  vomited  are  not  to  be  disregarded, 
for  they  can  enlighten  us  as  to  the  cause  of  the  vomiting.  To 
this  point  we  will  often  refer,  for  it  will,  without  doubt,  throw 
considerable  light  on  the  history  of  the  diseases  of  the  digestive 
tube.  I  will  only  remark  here  that  when  disorder  in  the  diges- 
tive functions  has  no  other  seat  than  the  stomach,  the  substances 
vomited  are  always  white,  sometimes  tinged  with  yellow,  and 
are  more  frequently  semi-liquid,  or  coagulated. 

There  is  but  little  to  be  said  upon  the  treatment  of  this  species 

*  Traite  des  Maladies  des  En  fans,  page  289. 


246  ON   THE    DISEASES   OP    INFANTS. 

of  gastric  indigestion.  For  the  most  part,  these  vomitings  are  of 
so  little  importance  that  they  hardly  require  any  attention.  This 
is  the  advice  of  Underwood,  who  observes  that  nurses  and  mo- 
thers regard  them  as  salutary,  and  consider  them  as  evidences  of 
flourishing  health. 

Yet  when  they  are  too  frequent,  when  the  child  becomes  pale 
and  thin  for  want  of  nourishment,  it  is  well  to  follow  the  advice 
of  Rosen.  The  first  thing  to  be  done  is  to  allow  the  child  a  very 
small  quantity  of  drink  at  once,  and  if  it  should  exhibit  all  the 
symptoms  of  indigestion,  after  having  taken  a  quantity  of  milk 
more  than  corresponds  with  the  capacity  of  the  stomach,  it  will 
be  necessary  to  excite  its  evacuation  by  tickling  the  uvula  with 
a  feather  dipped  in  olive  oil.  And  if  it  be  found  impossible  for 
the  stomach  to  digest  the  milk,  on  account  of  its  abounding  in 
caseum,  could  not  artificial  feeding  be  advantageously  substitut- 
ed for  sucking,  and  the  child  be  nourished  by  milk  and  water,  or 
with  whey  ?  If  neither  of  these  will  digest,  it  will  be  necessary 
to  try  some  other  kind  of  aliment — such  as  thin  pap,  gelatinous 
or  farinaceous  substances,  as  sago  or  arrowroot. 

If  these  reiterated  vomitings  be  accompanied  by  an  evident  ex- 
halation of  acid,  when  they  are  preceded  or  followed  by  the  ejec- 
tion of  ropy  mucus,  without  any  symptom  of  gastric  inflamma- 
tion, it  will  be  necessary  to  administer  a  few  grains  of  magnesia. 
It  is  unnecessary  to  unite  it  with  cummin,  or  any  other  aromatic, 
as  recommended  by  Rosen,  for  it  will  act  with  more  certainty 
without  this  mixture,  or  to  have  recourse  to  fennel  water,  in 
which  to  suspend  it ;  but  a  spoonful  of  sweetened  water  is  all 
that  is  needed  for  that  purpose.  M.  Gardien  advises  an  infusion 
of  rhubarb,,  or  magnesia  and  rhubarb  ;  but  it  should  be  remem- 
bered, before  it  is  used,  that  these  means  may  be  injurious  if 
there  exist  the  slightest  inflammation  of  the  stomach  ;  that  they 
are  not  rationally  indicated  because  there  is  vomiting,  for  a  num- 
ber of  causes,  which  we  will  consider  successively,  may  produce 
it ;  and  that,  although  it  is  possible  that  a  disturbance  in  the 
function  of  the  stomach  may  exist  without  an  inflammation  of 
this  organ,  yet,  for  the  most  part,  it  is  produced  by  a  phlegmasia 
or  by  an  alteration  in  some  part  of  the  digestive  tube.  This 
will  be  proved  in  the  course  of  our  researches. 

If  the  child  has  been  poisoned,  it  will  be  necessary  to  ascertain 


ON   THE    DISEASES   OP    INFANTS.  247 

the  nature  of  the  poisonous  substance^  that  it  may  be  treated  with 
the  appropriate  means.  We  will  refer,  for  the  necessary  infor- 
mation on  this  subject,  to  the  work  on  toxicology  by  Professor 
Orfila.  We  will  only  observe  that  the  salts  of  copper  or  mercu- 
ry, by  which  children  at  the  breast  are  more  often  apt  to  be  pois- 
oned, are  promptly  neutralized  by  the  administration  of  albumi- 
nous drinks,  especially  by  those  containing  the  white  of  an  egg. 

Art.  2. — Lesions  of  tlie  stomach,  with  or  without  disturbance  of  its  functions. 

If  I  should  take  the  symptoms  of  diseases  for  the  bases  of  my 
division,  I  should  be  obliged  to  unite  in  this  place  diseases,  the 
seats  of  which  have  no  connection  ;  for  the  various  derange- 
ments with  which  the  stomach  is  affected,  give  rise  to  symptoms 
so  different  that  it  is  sometimes  very  difficult  to  group  them  to- 
gether. But  in  dividing  the  affections  which  I  have  undertaken 
to  describe,  according  to  the  anatomical  lesions  which  produce 
them,  I  am  naturally  led  to  make  a  complete  pathology  of  the 
stomach. 

The  diseases  of  the  stomach,  developed  after  birth,  are  divided 
into  passive  congestions  and  inflammations. 

§  I.  Congestions  of  the  stomach. — We  have  seen  that  the 
stomach  of  a  child  just  born  is  almost  always  injected  with 
blood;  if  there  should  occur  ever  so  little  disturbance  in  the  ge- 
neral or  pulmonary  circulation,  the  abdominal  vessels  become 
engorged  with  black  fluid  blood,  which,  flowing  towards  the  ca- 
pillaries, inject  and  engorge  their  branches,  imparting  to  the 
abdominal  surfaces  an  appearance  more  or  less  red.  When  the 
bodies  of  these  children  are  opened,  there  is  found  on  the  inter- 
nal surface  of  the  mucous  membrane,  a  ramified  injection,  char- 
acterized by  its  bluish  appearance,  and  the  deeper  color  of  the 
depending  parts,  by  the  absence  of  tumefaction  with  friability  of 
the  mucous  membrane,  and  particularly  by  the  general  conges- 
tion of  the  large  venous  trunks  of  the  abdomen,  of  the  liver  and 
spleen,  venae  cavoe,  heart,  and  lungs.  The  blood  which  has 
accumulated  in  the  vessels  of  the  stomach  is  absorbed,  penetrates 
mechanically  to  the  cellular  tissue,  is  infiltrated  in  the  mucous 
membrane  itself,  and  is  exuded  on  the  surface  of  this  membrane, 
in  such  a  manner  as  to  color  with  greater  or  less  intensity  the 


248  ON    THE    DISEASES   OP    INFANTS. 

mucus  with    which  it  is  covered;  or   a  pa.ssive   hemorrhage 
occurs. 

The  instances  of  passive  congestions  of  the  stomach  are  so  nu- 
merous in  cliildren  t»'.  the  breast,  that  1  could  cite  a  large  num- 
ber  of  them  ;  but  I  will  confine  myself  to  tracing  the  history  of 
one  case  of  congestion  of  the  stomach,  which  exhibits  all  the 
anatomical  characters  that  have  been  enumerated. 


CASE  XXX. — Auguste  Bourbon,  a  boy,  aged  eight  days,  was 
brought  to  the  infirmary  on  the  2d  of  May,  by  his  nurse,  who  stated 
that  this  child  was  often  on  the  point  of  suffocation  ;  that  he  refused 
the  breast,  and  did  not  sleep.  Repossessed  a  strong  constitution; 
his  face  was  puffed  ;  the  limbs  (Edematous  and  purple,  and  the  res- 
piration difficult ;  the  Cry,  considerably  altered,  was  smothered,  and 
the  reprise,  husky  and  jerking,  could  be  heard  only  for  a  moment ; 
the  pulse  was  imperceptible  ;  the  beatings  of  the  heart  very  small  and 
irregular,  rising  at  the  most  to  fifty  in  a  minute ;  it  occasionally  hap- 
pened that  the  pulsations  were  for  a  moment  so  small  and  so  frequent 
that  it  was  with  difficulty  they  could  be  counted.  The  child  was 
enveloped  in  hot  wool,  and  frictions  of  "  eau  theriacale"  were  appli- 
ed to  the  trunk  and  limbs.  On  the  third,  the  upper  lip  was  consider- 
ably tumefied,  and  the  child  vomited  bloody  matters.  (Lotions  of 
sulphate  of  quinine.)  On  the  fourth,  the  sinking  increased ;  the  ejec- 
tion of  sanguineous  substances  continued,  and  death  occurred  that 
night  without  any  other  remarkable  symptom. 

The  post  mortem  examination  was  made  on  the  next  day.  There 
was  found  a  tumefaction  with  a  purple  redness  of  the  upper  lip  ;  the 
buccal  membrane  was  of  a  violet  color  ;  the  tongue  was  tumefied,  and 
appeared  ecchymosed  at  the  base  ;,  the  oesophagus  very  much  inject- 
ed ;  the  stomach  violet  red  in  its  whole  extent ;  its  walls,  which 
were  soft,  and  the  membranes  of  which  were  easily  separated,  were 
infiltrated  with  black  blood.  The  stomach  contained  a  large  quan- 
tity of  substances  of  the  consistence  of  mucus,  and  of  a  brown  and 
bloody  appearance,  resembling  in  every  respect  the  matters  vomited. 
The  liver  was  gorged  with  blood,  and  of  an  intense  red  ;  there  exist- 
ed on  its  surface  a  kind  of  sanguinolent  dew,  and  pale  liquid  blood 
was  found  effused  in  the  cavity  of  the  abdomen.  The  left  lung  cre- 
pitated ;  the  right  was  much  engorged,  and  did  not  crepitate  in  the 
least ;  the  pleura  on  this  side  contained  a  quantity  of  effused  blood. 
The  heart  and  large  vessels  were  very  much  engorged,  and  the  pa- 


ON   THE    DISEASES    OF    INFANTS.  249 

rietes  of  the  heart  were,  as  it  were,  soaked  with  blood,  and  a  small 
quantity  was  found  effused  in  the  pericardium. 

The  vessels  of  the  meninges,  and  of  the  surface  of  the  brain,  were 
considerably  injected  ;  the  same  was  the  case  with  the  plexus  cho- 
roides,  and  the  cerebral  pulp  was  of  a  deep  red. 

We  see  in  this  case  that  not  only  was  the  stomach  the  seat  of 
a  very  considerable  congestion,  but  also  that  all  the  other  organs 
were  in  the  same  condition ;  that  venous  blood  engorged  every 
part  of  the  blood  vessels,  and  that  it  flowed  in  the  most  remote 
vascular  ramifications,  infiltrating  the  organs  and  coloring  them, 
while  it  was  even  found  exuded  on  their  surfaces.  Thus,  then, 
this  coloration  of  the  stomach,  eflusion  of  blood  contained  in  this 
organ,  the  sanguinolent  vomiting  observed  during  life,  were,  in 
this  child,  the  result  of  a  true  passive  congestion,  which  is  very 
commonly  met  with  at  this  period  of  life.  It  is  true  that  the  san- 
guineous congestion  often  consists  of  nothing  more  than  a  simple 
injection,  and  is  not  always  accompanied  by  a  state  of  sangui- 
neous plethora  as  remarkable  as  was  the  subject  of  the  preceding 
case ;  but,  I  repeat  it,  tlfe  sanguineous  congestion  of  the  diges- 
tive passages,  in  consequence  of  the  difficulty  or  incomplete  es 
tablishment  of  respiration  and  circulation,  is  a  very  common  phe- 
nomenon in  the  first  period  of  life. 

The  symptoms  attending  this  passive  congestion  of  the  sto- 
mach are  nothing,  particularly  with  respect  to  the  digestive  ap- 
paratus, if  the  congestion  be  light ;  but  if,  on  the  contrary,  it 
exist  in  a  high  degree,  there  will  then  appear  some  derangement  in 
the  digestive  organs,  and  sometimes  with  sanguinolent  vomiting. 

But  it  is  not  simply  in  the  digestive  functions  that  we  must 
look  for  the  symptoms  from  which  we  are  to  infer  the  existence 
of  congestion  of  the  stomach ;  let  us  note  that  this  is  but  se- 
condary, that  it  is  the  effect  of  a  cause  which  has  existed  before  ; 
and  it  is  towards  the  seat  of  this  cause  that  our  attention  is  to  be 
directed.  Now,  every  time  we  see  a  child  born  with  all  the  signs 
of  sanguineous  plethora,  where  we  observe  the  respiration  be- 
coming established  with  difficulty,  and  the  characters  which  we 
shall  hereafter  indicate  as  being  those  of  pulmonary  congestion, 
all  uniting  with  sanguinolent  vomiting ;  we  shall  then  have  rea- 
son to  believe  the  existence  of  a  passive  congestion  of  the  sto- 

32 


250  ON  THE   DISEASES  OF    INFANTS. 

mach ;  because  experience  has  proved  that  this  lesion  is,  in  in- 
fants, as  in  adults,  the  result  of  a  disturbance  in  the  circulatory 
apparatus.  The  treatment  in  such  cases  ought  to  be  based  upon 
the  necessity  of  restoring  the  blood  to  its  habitual  channels,  of 
relieving  the  tissue  of  the  organs  from  the  superabundance  of  this 
fluid,  and,  above  all,  to  direct  our  remedies  to  the  congestion  of 
the  heart  and  lungs. 

Sanguineous  evacuations  are  the  proper  means  for  accelerat- 
ing the  subcutaneous  capillary  circulation.  The  manner  of  ac- 
complishing it  will  be  detailed  when  we  come  to  treat  of  the  dis- 
eases of  the  circulatory  apparatus.  It  is  sufficient  here  to  point 
out  the  object  of  the  treatment. 

§  II.  Inflammations  of  the  stomach. — Gastritis  is  an  in- 
flammation of  the  mucous  membrane  of  the  stomach  ;  but  what 
shades  does  this  inflammation  present !  What  varieties  of  form 
and  aspect  do  the  pathological  alterations  which  constitute  this 
afiection  exhibit !  In  order  to  describe  them  all  in  proper  order, 
I  shall  again  follow  the  analytic  method  which  was  adopted 
when  considering  stomatitis,  and  will  divide  inflammations  of 
the  stomach  in  the  following  manner. 

GASTRITIS. 

Erythematic, 

With  altered  secretion ; 

Follicular, 

With  disorganization  of  tissue. 

All  these  modifications  will  be  studied  with  reference  to  their 
anatomical  characters,  and  the  symptoms  which  accompany 
them ;  they  may  exist  either  in  an  acute  or  chronic  state ;  one 
may  succeed  the  other,  and  it  is  possible  that  several  may  exist 
at  the  same  time. 

§1.  Erythematic  gastritis. — Erythematic  inflammation 
of  the  stomach  presents  itself  under  the  appearance  of  a  ramified 
or  capillary  injection ;  of  a  redness  diff'used  in  patches  to  a 
greater  or  less  extent ;  of  irregular  striae,  which  very  often  follow 
the  course  of  the  corrugations  of  the  stomach  ;  and  finally,  of  that 
of  a  number  of  closely  approximated  red  points.  These  differ- 
ent appearances  may  be  either  accompanied  or  not  by  a  tume- 


ON    THE    DISEASES    OF    INFANTS.  251 

faction  and  friability  of  the  mucous  tissue.  Sometimes  the  mu- 
cus of  the  stomach  is  thick,  tenacious,  and  more  abundant  than 
in  the  ordinary  state  ;  but  this  character  of  the  inflammation  is 
not  constant. 

The  seat  of  the  inflammatory  ramified  injection  is  in  the  ves- 
sels of  the  stomach ;  that  of  the  capilliform  inflammation  is  in 
their  capillary  ramifications  ;  that  of  the  patches,  strias,  and  red 
points,  in  the  mucous  membrane ;  and  especially,  as  M.  Leuret 
has  remarked,  in  the  papilla  or  villosities  of  the  mucous  mem- 
brane, which  appear  slightly  tumefied.  Nevertheless,  this  mo- 
dification of  erythematic  redness  may  present  itself  independent- 
ly of  the  tumefaction  of  the  villi. 

Erythematic  inflammation  of  the  stomach  will  be  milder  in 
proportion  as  the  internal  membrane  is  less  friable  and  less  tume- 
fied. Of  all  the  different  kinds  of  redness  that  which  we  have  de- 
signated as  ramiform,  is  the  result  of  the  slightest  degree  of  in- 
flammation. The  pointed  capilliform  or  striated  redness  should 
be  considered  as  the  evidences  of  an  inflammation  more  and  more 
acute.  '^ 

These  various  morbid  aspects  are  very  often  the  first  degree 
of  a  very  intense  inflammation,  great  disorganization,  or  a  trans- 
formation of  tissue,  and  are  observed  separately  or  together  in  the 
same  individual. 

It  is  very  easy  to  mistake  a  certain  red  appearance  which  is 
owing  to  a  state  of  congestion,  for  an  erythematic  inflammation  ; 
it  is  necessary,  therefore,  to  keep  always  in  mind  the  seat  of  this 
redness,  and  the  state  of  fulness  or  vacuity  of  the  abdominal  ves- 
sels. Passive  redness  is  always  found  in  the  lowest  parts  of  the 
organ,  existing,  at  the  same  time,  with  a  general  congestion  of  the 
vessels  of  the  digestive  tube  of  the  large  abdominal  trunk,  and  of 
the  right  cavities  of  the  heart.  Active  or  inflammatory  redness 
exists  more  often  independently  of  these  circumstances,  and  fre- 
quently attends  tumefaction  and  friability  of  the  mucous  mem- 
brane. 

The  anatomical  characters  of  erythematic  gastritis  being  esta- 
blished, let  us  now  see  what  are  the  symptoms  which  corre- 
spond to  it,  and  which  together  constitute  the  important  part 
of  the  history  of  the  disease.  Here  it  is  necessary  to  exam- 
ine cases   without  prejudice,  and   select  those  without   com- 


252  ON   THE    DISEASES   OP    INFANTS. 

plicatiorij  otherwise  we  cannot  draw  any  just  and  precise  con- 
clusion. 

CASE  XXXI. — Erythematic  Gastritis. — Louise  Plantier,  aged 
four  days,  remarkable  for  the  color  of  her  face,  and  the  firmness  of 
her  flesh,  entered  the  infirmary  on  the  1st  of  January,  1826,  because 
sJie  had  refused  the  breast,  and  had  vomited  yellow  acid  matter  either 
immediately  or  some  time  after  drinking.  (Gummed  barley-wa- 
ter, milk  and  water.)  On  the  2d  of  January  the  vomiting  in- 
creased,— the  inferior  extremities  were  oedematous,  and  hard  to  the 
touch,  the  face  pale  and  pinched,  respiration  difficult,  skin  cold,  pulse 
slow  and  irregular.  The  abdomen  was  not  tympanitic,  and  could  be 
pressed  without  giving  pain ;  yet  when  pressure  was  made  on  the 
epigastric  region,  a  sudden  contraction  of  the  face  and  the  cries  of 
the  child  indicated  that  she  experienced  pain.  [Sweetened  water, 
milk  and  water.)  On  the  3d  of  January  there  was  a  general  sink- 
ing ;  the  face  became  thin,  and  expressive  of  great  pain ;  the  child 
cried  often,  and  refused  every  thing  that  was  given  her  to  drink,  yet 
did  not  vomit ;  the  stools  were  natural.  On  the  fourth  and  fifth  in  the 
same  condition ;  on  the  sixth  she  died.  The  post  mortem  examina- 
tion was  made  the  following  day.  The  exterior  of  the  body  still  re- 
tained much  of  its  original  embonpoint.  The  mouth  and  oesophagus 
were  healthy ;  there  was  a  very  intense  redness  in  the  stomach,  near 
its  cardiac  orifice,  which  extended  the  length  of  the  lesser  curvature. 
The  mucous  membrane  in  this  part  was  much  tumefied,  and  could  be 
raised  with  the  nail  with  great  ease.  In  the  remainder  of  the  organ 
there  existed  a  strongly  marked  capilliform  injection.  The  intestinal 
canal,  liver,  and  spleen  were  healthy.  There  was  a  small  quantity  of 
clear  serum  effused  in  the  right  cavity  of  the  thorax  ;  the  lung  of  this 
side  was  slightly  hepatized  in  the  middle  lobe ;  the  left  crepitated 
strongly.  The  trachea  and  bronchise  were  healthy,  and  so  were 
also  the  heart,  large  vessels,  and  brain. 

The  disturbance  in  the  digestive  functions  was  not  observed, 
except  at  the  commencement  of  the  disease.  It  ought  also  to  be 
remarked,  that  the  vomiting  occurred,  at  all  times,  either  a  short 
or  a  long  time  after  taking  drinks, — that  the  physiognomy  of  the 
child,  which  was  indicative  of  pain,  almost  constantly  gave  still 
greater  evidence  of  its  existence,  on  pressing  the  epigastric  re- 
gion,—that  the  abdomen  was  not  tympanitic, — and,  lastly,  that 
notwithstanding  this  assemblage  of  local  symptoms,  there  existed 


ON   THE    DISEASES    OF    INFANTS.  253 

no  evident  sign  of  febrile  reaction,  a  circumstancej  the  import- 
ance of  which  will  be  considered  in  another  place. 

It  is  very  rare  to  find,  in  infants  at  the  breast,  a  simple  inflam- 
mation of  the  stomach,  without  some  portion  of  the  intestinal 
tube  being  at  the  same  time  inflamed ;  and  the  symptoms  of  ery- 
thematic  gastritis,  like  the  case  just  mentioned,  are  far  from  pre- 
senting themselves  in  all  children  with  the  like  clearness  and 
simplicity.  It  must  always  be  by  the  aid  of  an  examination  and 
close  attention  alone  that  it  can  be  possible  for  us  to  separate 
them,  and  to  distinguish  them  from  the  epiphenomena,  or  other 
accompanying  symptoms. 

Erythematic  gastritis  is  almost  always  acute ;  yet  it  may  be- 
come chronic  ;  and  then,  taking  a  new  character,  may  be  replaced 
by  ulceration,  gangrene,  or  softening  of  the  membrane. 

The  most  common  complication  of  this  disease  is  enteritis ;  for 
in  one  hundred  and  fifty  cases  of  inflammation  of  the  sub-dia- 
phragmatic portion  of  the  digestive  tube  which  I  examined  with 
care,  there  were  ninety  cases  of  gastro-enteritis,  fifty  of  enteritis 
without  gastritis,  and  only  ten  cases  of  gastritis  without  enteritis. 
From  this  statement  the  natural  deduction  is,  that  whenever  en- 
teritis is  developed,  we  may  infer  the  existence,  at  the  same  time, 
of  gastritis.  But  whatever  embarrassments  a  physician  may  ex- 
perience in  the  diagnosis  of  gastritis  in  young  infants,  in  conse- 
quence of  the  obscurity  of  the  symptoms,  and  the  frequency  of 
the  complications,  this  cannot  have  much  effect  on  the  treatment, 
since  the  proper  means  for  the  management  of  enteritis  are  also 
applicable  to  gastritis,  and  vice  versd. 

Yet  the  embarrassment  of  which  we  have  spoken  can  hardly 
exist,  except  in  the  case  of  simple  erythematic  gastritis ;  for  so 
soon  as  the  mucous  membrane  of  the  stomach  becomes  the  seat 
of  a  more  strongly  marked  lesion,  the  symptoms  then  assume  a 
more  cognisable  character ;  this  is  what  we  have  already  seen 
in  reviewing  the  various  modifications  of  gastritis  pointed  out 
above. 

§  II.  Gastritis,  with  altered  secretion,  or  muguet  op 
THE  STOMACH. — I  havc  already  demonstrated  that  muguet  is 
nothing  more  than  an  altered  secretion  of  the  buccal  or  oesopha- 
geal mucous  membrane.  The  same  phenomena  may  occur  in 
the  stomach  when  the  intestinal  membrane  becomes  the  seat  of 


264  ON   THE    DISEASES    OF   INFANTS. 

inflammation.  Some  have  vainly  attempted  to  prove,  by  reason- 
ing, that  mugiiet  cannot  form  in  the  stomach.  I  shall  only  an- 
swer by  facts  which  cannot  be  doubted,  because  I  will  exhibit 
them  with  all  their  details,  and  with  the  fidelity  necessary  to  re- 
move any  doubt  existing  on  the  subject. 

This  altered  secretion  is  much  more  rare  in  the  stomach  than 
in  the  oesophagus  or  mouth  ;  for,  in  two  hundred  and  fourteen 
cases  of  muguet,  observed  in  the  medical  infirmary  of  the  Enfans 
Trouves  during  the  year  1826,  I  saw  but  three  cases  of  muguet 
of  the  stomach,  and  only  two  of  the  intestinal  canal ;  from  which 
it  follows  that  the  mucous  membrane  of  the  digestive  tube  is 
much  more  exposed  to  the  altered  secretion  constituting  muguet 
in  proportion  as  it  approaches  the  buccal  cavity, — that  is  to  say, 
in  proportion  as  it  is  found  more  immediately  connected  with 
the  external  air.  Does  the  contact  of  the  air  with  an  inflamed 
surface  contribute,  in  any  degree,  to  concrete  the  secretion  from 
that  surface  ?  This  is  a  very  natural  question  in  this  place,  but 
one  which  is  very  difficult  to  answer.  Whatever  be  the  cause, 
let  us  listen  to  the  relation  of  the  cases  of  which  we  have  spoken. 

CASE  XXXII. — Muguet  of  the  stomach. — Louise  Labry,  aged  13 
days,  was  placed  under  our  care  on  the  8th  of  July.  She  was  of 
a  feeble  constitution.  Two  days  before  her  admission  she  had  be- 
come pale,  and  refused  the  breast,  although  she  did  not  vomit  what 
she  was  forced  to  drink.  On  her  entrance  into  the  infirmary  she  ex- 
hibited an  intense  redness  of  the  buccal  membrane,  and  a  thick  layer 
of  muguet  spread  on  the  internal  surface  of  the  cheeks  and  the  base 
of  the  tongue.  (Gummed  barley-water,  emollient  gargle,  milk  and 
water.)  On  the  tenth  there  appeared  to  be  a  commencement  of  ma- 
rasmus ;  she  vomited  her  drinks,  but  had  no  diarrhcea ;  abdomen  was 
not  tense.  On  the  fourteenth  vomiting  of  yellow  matter  supervened, 
and  a  much  thicker  layer  of  muguet  was  formed  on  the  tongue  and 
buccal  parietes.  Between  the  intervals  of  these  membranous  layers 
appeared  the  mucous  membrane,  of  a  deep  cherry  red.  The  skin 
was  cold,  the  extremities  purple,  and  the  pulse  small.  The  child  died 
at  night. 

Post  mortem  examination. — Emaciation  and  general  paleness  of 
the  integuments.  There  still  existed  a  thick  layer  of  muguet  upon  the 
tongue,  pharynx,  and  oesophagus.  The  mucous  membrane  of  the 
stomach  was  very  red,  thick,  and  friable ;  and  a  large  layer  of  muguet, 


ON   THE    DISEASES    OP    INFANTS.  255 

composed  of  a  considerable  number  of  small  shining  white  points, 
covering  the  villosities  of  this  membrane,  which  together,  might  be 
compared  to  a  thin  coat  of  hoar-frost  spread  over  fine  moss.  These 
white  points,  upon  scraping  them,  could  be  raised  with  the  scalpel, 
but  they  resisted  rubbing  with  the  fingers.  Some  detached  points 
were  found  floating  in  the  mucus  of  the  stomach.  None  of  the  muci- 
parous follicles  could  be  seen.  A  few  transverse  red  striae  existed  in 
the  duodenum,  and  there  was  found  a  passive  ramiform  injection  in 
the  ileo-caecal  region,  and  at  the  commencement  of  the  large  intes- 
tines ;  the  liver,  considerably  engorged  with  blood,  exhibited  a  green 
slate-color  ;  the  lungs  and  heart  were  healthy  ;  the  brain  very  much 
injected,  and  the  longitudinal  sinews  filled  with  blood. 

There  was  no  symptom  here  which  would  have  enabled  us 
to  have  detected  the  presence  of  muguet  in  the  stomach  ;  yet,  as 
the  symptoms  of  gastritis  supervened,  after  the  appearance  of  mu- 
guet in  the  mouth,  we  are,  therefore,  led  to  believe  that  this  pel' 
licular  secretion  was  not  developed  in  the  stomach,  until  after  it 
had,  in  some  sort,  passed  through  the  pharynx  and  oesophagus. 
Let  us  again  note  the  absence  of  all  symptoms  of  re-action,  not- 
withstanding the  violent  inflammation  of  these  parts ;  but,  in 
place  of  generalizing,  we  will  pursue  still  further  the  examina- 
tion of  facts 

CASE  XXXIII. — Muguet  of  the  mouth,  stomachy  and  (Esopha- 
gus. On  the  26th  of  August,  1826,  Marie  Galet,  aged  four  days, 
entered  the  infirmary.  She  was  small,  feeble,  and  very  pale,  and  was 
afifected  with  a  copious  diarrhoea.  (Rice  ivater;  abstinence.)  On 
the  1st  of  September  the  edges  of  the  tongue  were  covered  with  a 
few  points  of  muguet,  and  the  mucous  membrane  of  the  mouth  became 
red  and  very  dry.  On  the  2d  of  September  the  muguet  formed 
a  thick  layer,  the  diarrhoea  was  suspended,  the  abdomen  was  retracted, 
and  without  pain  on  pressure.  The  skin  was  burning,  and  yet  the 
pulse  was  so  small  that  it  was  very  difficult  to  feel  it.  {Same  treat- 
ment.) On  the  5th  of  September  there  was  an  extreme  paleness  of 
the  face,  and  emaciation  had  commenced  ;  the  buccal  membrane  was 
continually  covered  with  new  layers  of  muguet.  On  the  8th  of 
September,  vomiting,  which  had  not  before  been  observed,  occurred, 
and  the  child  rejected  all  the  drinks  that  were  given.  That  part  of 
the  buccal  membrane  which  was  free  from  muguet,  was  of  an  intense 


256  ON   THE    DISEASES   OP    INFANTS. 

red ;  marasmus  made  rapid  progress  ;  the  skin  was  not  very  warm ;  the 
pulse  small,  and  did  not  beat  but  seventy  to  eighty  in  a  minute.  The  face 
of  the  child  gave  constant  indications  of  pain;  several  deep  wrinkles 
were  formed  at  the  root  of  the  nose,  and  the  commissure  of  the  lips 
was,  as  it  were,  drawn  backward.  She  remained  in  the  same  state 
until  the  end  of  the  month,  when  she  became  very  much  emaciated, 
with  occasional  diarrhoea,  and  constant  vomiting ;  small  points  of 
muguet  also  appeared  on  the  base  of  the  tongue.  In  the  beginning  of 
September  the  vomiting  continued,  and  the  matters  thus  discharged 
were  of  a  yellow  color;  the  face  was  continually  pinched,  the  abdo- 
men shrunken,  the  lower  extremities  much  wasted  ;  the  cry  was  feeble, 
and  could  scarcely  be  heard ;  stools  were  liquid,  yellow,  and  scanty. 
The  treatment  was  confined  to  a  mild  ptisan,  and  emollient  gargles. 
After  having  arrived,  insensibly,  at  the  last  stage  of  emaciation  and 
feebleness,  she  expired  on  the  13th  of  September,  at  night. 

On  examining  the  body  on  the  next  day,  the  parietes  of  the  mouth, 
internal  surface  of  the  lips,  and  the  surface  of  the  tongue,  were  found 
covered  with  a  thick  layer  of  muguet,  which,  in  some  places,  could 
be  raised  in  patches.  The  glottis  was  healthy,  but  the  lateral  walls  of 
the  pharynx  were  filled  with  a  number  of  points  of  muguet ;  the  entire 
internal  surface  of  the  oesophagus  was  also  covered  with  it ;  it  there 
appeared  in  the  form  of  thick  flakes,  ranged  in  parallel  lines,  from 
above  downward,  between  which  the  epithelium  formed  furrows  of 
various  depths  ;  this  extended  to  the  cardia.  Beneath  the  excretion, 
the  epithelium  appeared  white. 

The  mucous  membrane  of  the  stomach,  especially  at  the  greater 
curvature,  was  very  red  and  much  swelled ;  but,  at  the  lesser  curva- 
ture, this  membrane  was  covered  with  a  large  plate  of  muguet,  result- 
ing from  the  agglomeration  of  a  number  of  small  white  shining  pelli- 
cular points,  which  resisted  any  efforts  to  remove  them  with  the  nail, 
but  which  were  easily  detached  by  cutting  with  the  scalpel ;  the  vil- 
losities  then  appeared  very  prominent,  red,  and  in  a  sort  of  turges- 
cence  or  erection.  When  examined  through  a  magnifying  glass, 
there  was  discovered  between  them  some  appearance  of  muguet,  and 
the  summit  of  those  scraped  was  bloody. 

The  small  intestines  presented  here  and  there  a  slight  redness ; 
the  large  intestines  were  healthy ;  the  liver  was  gorged  with  blood  ; 
the  bile  was  limpid  and  green ;  the  lungs  were  engorged  at  their  pos- 
terior part ;  the  foetal  openings  had  already  begun  to  be  obliterated  ; 
the  brain  was  healthy. 


ON   THE  DISEASES   OF    INFANTS.  257 

In  this  case,  as  in  the  preceding,  we  find  a  thick  layer  of  mu- 
guet  in  the  stomach,  but  without  any  symptom  that  could  indi- 
cate its  presence ;  there  existed  solely  symptoms  of  chronic  gas- 
tritis and  OBSophagitis.  It  should  be  noted  that  the  symptoms,  at 
the  head  of  which  we  place  the  vomiting  of  drinks  and  of  yellow- 
ish matters,  did  not  appear  until  after  the  appearance  of  muguet 
of  the  mouth,  a  circumstance  coinciding  with  what  was  observed 
in  the  preceding  case. 

The  following  case  exhibits  muguet  of  the  stomach  complicat- 
ed with  follicular  inflammation  and  gelatinous  softening;  this 
will  naturally  lead  us  to  the  study  of  other  varieties  of  gastritis. 

CASE  XXXIV. — Muguet  of  the  stomach,  gelatinous  soften- 
ing.— Victorine  Larue,  aged  six  days,  entered  the  infirmary  on  the 
6th  of  September.  She  appeared  to  possess  a  moderate  degree  of 
strength ;  was  affected  with  a  diarrhoea,  consisting  of  liquid  yellow 
discharges  ;  the  abdomen  was  tense,  and  the  integuments  Avere  tinged 
with  yellow ;  the  tongue  was  dry  at  the  point ;  a  very  intense  red- 
ness existed  around  the  anus.  (Gummed  rice-water,  milk  and  water. ^ 
On  the  8th  of  September,  the  same  general  condition  continued  ;  the 
abdomen  was  more  tender  and  painful  about  the  epigastric  region 
than  in  other  parts,  for  the  child  cried  when  pressure  was  made  on 
this  part.  On  the  eleventh,  several  points  of  muguet  appeared  on 
the  edges  of  the  tongue ;  the  jaundice  had  disappeared  ;  the  skin  was 
of  a  medium  heat ;  the  pulse  natural,  (eighty.)  The  same  treatment 
was  continued.  On  the  twelfth,  the  diarrhoea  ceased ;  vomiting  of 
drinks  took  place ;  and  the  muguet  continued  to  increase.  On  the 
thirteenth,  the  muguet  had  spread  on  the  tongue  and  the  parietes  of 
the  mouth  under  the  form  of  a  thick  layer ;  the  vomiting  continued  ; 
the  face  was  much  altered,  and  a  number  of  wrinkles  were  observed 
at  the  root  of  the  nose,  together  with  a  retraction  of  the  commissure 
of  the  mouth.  For  twenty-four  hours,  the  cries  and  restlessness  of 
the  child  were  incessant,  yet  without  any  convulsive  movement.  The 
drinks  which  were  given  were  vomited  without  any  effort,  and  when 
the  epigastric  region  was  pressed,  the  child  cried  violently,  and  con- 
tinued to  cry  until  she  became  exhausted  with  fatigue  and  pain. 
Death  occurred  in  the  midst  of  these  agonies  on  the  13th  of  Septem- 
ber, without  any  febrile  symptom  having  made  its  appearance. 

The  examination  of  the  body  was  made  on  the  next  day,  and  a 
thick  layer  of  mucus  was  found  upon  the  tongue  and  the  buccal  pa- 
rietes ;  the  glottis  was  healthy,  but  the  pharynx  was  covered  with  a 

33 


258  ON    THE    DISEASES   OP    INFANTS. 

number  of  points  of  muguet ;  they  also  appeared  in  the  whole  length 
of  the  a5sophagus,  existing  in  the  form  of  small  agglomerated  points, 
ranged  longitudinally  even  to  the  cardiac  orifice,  where  they  ceased 
with  the  epithelium. 

The  mucous  membrane  of  the  stomach  was  red  in  most  of  its  ex- 
tent, and  a  gelatinous  softening  was  found  at  the  great  tuberosity, 
about  three  inches  in  length,  in  the  centre  of  which  the  stomach  was 
perforated.  The  borders  of  this  perforation  were,  as  it  were,  fringed, 
and  exhibited  some  thin  filaments,  as  if  recently  torn.  Near  the 
spleen  there  was  found  an  effusion  of  mucus  from  the  stomach,  yet 
no  peritonitis  existed.  Several  layers  of  thick  muguet,  irregularly 
disseminated,  existed  on  the  mucous  membrane  of  the  stomach.  There 
appeared  in  the  lesser  curvature  a  number  of  muciparous  follicles, 
slightly  tumefied,  and  surrounded  by  a  red  circle.  Some  of  their 
orifices  were  open,  and  were  of  a  red  color.  The  villosities  were 
every  where  prominent,  and  the  mucous  membrane  was  thick  and 
slightly  friable  in  the  place  where  it  was  not  softened. 

Red  transverse  striae  existed  the  whole  length  of  the  small  in- 
testines ;  the  large  intestines  were  healthy  ;  the  lungs  were  crepi- 
tant ;  the  venae  cavae  and  the  right  cavities  of  the  heart  were  gorged 
with  blood  ;  the  brain  was  slightly  injected. 

This  case  may  serve  not  only  to  furnish  us  with  another  in- 
stance of  muguet  of  the  stomach,  but  also  with  symptoms  of 
gastritis.  In  fact,  the  vomiting,  tension,  and  pain  of  the  epigas- 
trium, painful  cries  when  this  region  was  compressed,  alteration 
of  the  physiognomy,  the  expression  of  which  indicated  the  severe 
sufferings  of  the  child  even  to  the  latest  moments  of  life,^ — the 
whole  together  were  sufficient  to  produce  a  belief  of  the  existence 
of  gastritis ;  and  this  supposition,  which  the  observations  of  the 
symptoms  enabled  us  to  make,  was  fully  confirmed  upon  a  post 
mortem  examination  of  the  body.  These  three  marked  signs  of 
gastritis,  therefore,  should  not  be  forgotten ;  and  when  they  ap- 
pear even  in  ever  so  slight  a  manner,  let  them  be  carefully 
studied.  In  the  science  of  diagnosis,  we  have  need  of  all  the  as- 
sistance of  reasoning  to  second  our  observations,  and  are  often 
obliged  to  draw  our  conclusions  from  experience  and  analogy. 
The  senses  and  judgment  ought  then  to  aid  us  continually  in  the 
study  of  diseases,  that  their  seat  and  nature  may  be  discovered. 
But  let  us  return  to  our  subject. 


ON   THE    DISEASES   OF   INFANTS.  259 

The  gastritis  which  caused  the  death  of  this  child,  exhibited, 
at  the  same  time,  several  varieties  of  inflammation.  In  fact,  we 
found  besides  the  erythematic  redness,  accompanied  by  a  sensible 
tumefaction  of  the  external  membrane,  an  altered  secretion  con- 
stituting muguet ;  inflammation  of  the  muciparous  follicles,  to 
which  I  reserved  the  name  of  aphthae ;  and,  finally,  a  softening, 
concerning  the  nature  of  which  I  shall  presently  offer  some  re- 
marks. This  case  deserves  our  attention  ;  it  proves  that  the  dif- 
ferences of  inflammation  arise  the  most  frequently  from  a  differ- 
ence in  their  seat,  and  that  the  cause,  or  inflammatory,  stimulus, 
having  acted  on  the  stomach  of  the  child  whose  age  and  consti- 
tution exposed  it,  at  the  same  time,  to  all  the  shades  of  phlegma- 
sia which  can  affect  this  organ,  it  is  not  surprising  that  all  these, 
affections  should  coexist. 

But  it  will  naturally  be  asked,  by  what  sign  is  it  possible  to  re- 
cognise muguet  of  the  stomach  ?  There  is  no  positive  symp- 
tom to  mark  the  existence  of  this  disease  ;  yet  it  must  be  noted, 
that  in  the  three  cases  just  stated,  evident  symptoms  of  gastritis 
were  manifested  after  the  appearance  of  muguet  of  the  mouth. 
Now,  can  it  not  be  presumed,  when  stomatitis  or  oesophagitis 
with  muguet  has  existed  in  an  infant,  a  gastritis  occurs,  that  the 
latter  may  also  be  accompanied  with  muguet  ?  This  will,  never- 
theless, be  but  a  presumption,  for  muguet  of  the  stomach  is  very 
rare.  In  this  incertitude,  the  physician  will  remember  that  he 
has  gastritis  to  encounter,  and  that  the  evidence  of  this  affection 
is  present  in  a  very  unequivocal  manner,  so  as  not  to  leave  a 
doubt  of  its  development  nor  of  the  means  of  treatment.  Before 
entering  on  the  treatment  of  gastritis  in  young  infants,  let  us 
continue  the  examination  of  the  varieties  of  this  inflammation. 

§  III.  Follicular  gastritis. — We  have  already  studied  the 
inflammation  of  the  follicular  apparatus  on  the  mucous  membrane 
of  the  mouth  and  oesophagus  ;  the  stomach,  where  this  secretory 
apparatus  also  exists,  may  present  the  same  alteration. 

The  follicles  of  the  stomach  never  exist  grouped  or  accumu- 
lated in  the  form  of  plexuses,  as  in  the  intestines  ;  but  they  are 
generally  separate,  and  may  experience  two  kinds  of  development. 

They  sometimes  appear  under  the  form  of  small,  white,  round, 
slightly  projecting  granulations,  terminating  in  a  black  point, 
which  marks  their  excretory  orifices ;  sometimes  they  inflame. 


260  ON   THE    DISEASES   OP    INFANTS. 

tumefy  considerably,  and,  finally  ulcerating,  become  disorgan- 
ized. In  the  former  case  they  give  rise  to  but  few  symptoms ;  in 
the  latter,  they  are  accompanied  by  the  symptoms  of  intense  gas- 
tritis, and  may  cause  the  death  of  the  child. 

It  is  rare  for  simple  and  uninflamed  follicles  to  appear  in  the 
stomach  alone,  without  showing  themselves  in  other  parts  of  the 
digestive  tube ;  they  generally  occupy  several  points  of  the  diges- 
tive tube  at  the  same  time,  and  generally  show  themselves  develop- 
ed in  this  manner  at  the  period  of  the  first  dentition.  I  will  re- 
turn hereafter  to  the  consideration  of  this  general  development 
of  the  follicular  apparatus  of  the  digestive  tube. 

But  the  inflammatory  development  of  the  follicles  often  occurs 
in  the  stomach  alone,  without  showing  itself  in  any  other  part  of 
the  intestinal  canal.  I  have  already  given  an  example  of  foUi 
cular  ulcerations  observed  in  young  infants.  I  noted  the  ana 
tomical  characters  of  these  kinds  of  ulcerations,  and  observed 
that  the  vomiting,  of  a  brownish  sanguinolent  material,  may  be 
the  evidence  of  their  existence.  I  will  confine  myself  here  to 
general  considerations  on  this  species  of  alteration. 

During  the  year  1826,  I  examined  fifteen  cases  of  follicular 
ulcerations  of  the  stomach  ;  eight  of  these  were  in  children  aged 
from  four  to  six  days  ;  six  from  eight  to  twelve  days ;  and  one 
only  of  them  three  weeks  old.  From  this  it  appears  that  the 
younger  children  are,  the  more  are  they  exposed  to  follicular  in- 
flammation of  the  stomach.  In  neither  of  these  cases  did  any 
well-marked  febrile  symptom  exist ;  they  were  only  remarkable 
for  their  state  of  sinking  and  feebleness,  the  inevitable  result  of 
the  pathological  condition  of  the  essential  organ  of  digestion,  the 
impossibility  or  disturbance  of  which  process  would  quickly 
cause  the  feebleness  and  death  of  these  children.  Several  of 
them  were  at  the  same  time  affected  with  other  serious  diseases ; 
such  as  encephalitis,  softening  of  the  brain,  pneumonia,  and  en- 
teritis. One  had  gastritis  alone,  and  to  its  progress  and  intensity 
the  child  appeared  to  succumb  at  the  age  of  four  days. 

The  diagnosis  and  treatment  of  this  disease  is  contained  in 
that  of  gastritis  in  general.  The  prognosis  is  unfavorable  in 
proportion  to  the  prostration,  feebleness,  and  early  age  of  the 
child ;  and  also  to  the  greater  quantity  of  black  sanguinolent 
matters  vomited. 


ON   THE    DISEASES    OF    INFANTS.  261 

§  IV.  Gastritis  with  disorganization  of  tissue. — The 
different  varieties  of  gastritis  which  we  have  already  mentioned, 
may  lead  to  a  true  disorganization  of  tissue,  since  they  are  some- 
times followed  by  ulcerations  more  or  less  deep;  hence  they 
might  be  mentioned  here ;  but  I  shall  now  confine  my  remarks 
to  the  violent  and  sudden  inflammation  of  the  internal  mem- 
brane of  the  stomach,  under  the  influence  of  which  a  disorgani- 
zation quickly  ensues  ;  such  are  gangrene  and  gelatinous  soften- 
ing of  the  stomach. 

1st.  Gangrene  of  the  stomach. — Gangrene  of  the  stomach  is 
an  occurrence  quite  rare  in  young  infants.  I  have  not  often  ob- 
served it;  yet  its  development  is  possible,  and  may  show  itself,  as 
in  adults,  under  the  form  of  various  sized  eschars,  which,  on  be- 
ing detached,  give  rise  to  perforations,  followed  by  fatal  symp- 
toms. M.  Denis  has  seen  one  case  where  "  he  found  the  mu- 
cous membrane  of  a  deep  brown,  and  difiiising  an  infectious 
odor,  reduced  here  and  there  to  a  putrescent  state,  easy  to  be 
raised  in  soft  shreds.  These  were  macerated  in  a  fluid,  the 
color  of  the  lees  of  wine,  and  it  could  only  be  attributed  to  gan- 
grene from  excess  of  inflammation."* 

I  have  seen  an  instance  of  destruction  of  the  mucous  mem- 
brane of  the  stomach  to  a  certain  extent,  caused  probably  by 
gangrene  supervening  after  violent  inflammation.  The  follow- 
ing is  the  history  of  this  interesting  case. 

CASE  XXXV. — Alexandrine  Liseman,  aged  three  days,  entered 
the  infirmary  on  the  3d  of  March,  with  the  following  symptoms : 
On  removing  the  clothes,  a  quantity  of  black  blood  was  found,  which 
had  been  discharged  from  the  anus.  The  child  also  vomited  the 
same  in  large  quantities.  She  was  healthy,  and  the  limbs  fat,  and 
the  whole  surface  of  the  body  was  jaundiced.  There  was  but  little 
movement ;  the  face  was  pale  ;  the  lips  discolored  ;  the  integuments 
flabby ;  the  cry  complete,  but  feeble  ;  the  pulse  extremely  slow  and 
small.  {Sweetened  water,  dry  frictions  to  the  body.)  On  the  third, 
the  same  state  continued.  On  the  fourth,  the  stools  were  black  and 
pitchy ;  the  child,  who  had  not  ceased  vomiting,  ejected  the  same 
kind  of  substance.  Yet  the  general  heat  of  the  skin  was  a  little  more 
elevated,  and  the  pulse  was  also  raised,  beating  about  seventy ;  the 

*  Denis  loc.  cit,  p.  56. 


262  ON   THE    DISEASES   OP   INFANTS. 

face  less  purple,  but  the  cry  continued  feeble.   (Sweetened  wine  and 
water.)     The  child  died  in  the  afternoon. 

Post  mortem  examination. — The  exterior  exhibited  a  tolerably 
strong  frame  ;  the  integuments  were  discolored  ;  the  mouth  and  sto- 
mach were  healthy ;  but  the  mucous  membrane  of  the  stomach  pre- 
sented, near  the  cardiac  orifice,  a  perfect  destruction  to  the  extent  of 
a  thirty  sous  piece,  the  centre  of  which  was  colored  with  black  blood, 
and  the  edges  irregularly  fringed  and  black,  and  had  the  appearance 
of  having  been  burned.  Behind  this  black  circle,  the  mucous  mem- 
brane was  thick,  of  a  violet  color,  and  was  easily  reduced  to  a  pulp. 
The  whole  surface  of  the  stomach  was  covered  with  semi-liquid  sub- 
stances, of  a  brown  color,  mixed  with  bloody  striae  ;  and  the  mucous 
membrane  beneath  these  substances  appeared  very  thin  and  color 
less,  particularly  near  the  pylorus.  The  small  intestines  were  co- 
lored yellow  by  the  bile,  and  contained  some  coagulated  blood.  The 
large  intestines  were  healthy.  The  liver  was  exsanguineous  and  pale, 
the  spleen  small  and  slightly  injected. 

The  lungs  were  healthy,  colorless,  exsanguineous,  and  very  .cre- 
pitant. The  heart  was  white  and  empty  ;  the  large  vessels  were  in 
the  same  state. 

The  base  of  the  cranium  contained  a  little  bloody  serum  ;  the  brain 
was  very  pale ;  the  ventricles  contained  a  little  serosity. 

It  is  evident  that  this  child  perished  from  hemorrhage,  and 
every  thing  induces  the  belief  that  this  was  caused  by  the  de- 
struction of  the  vessels  passing  over  the  parietes  of  the  stomach. 
The  rapid  progress  of  the  gangrenous  inflammation,  the  traces 
of  which  were  still  evident  in  the  burned  appearance  of  the  bor- 
ders, doubtless  produced  the  loss  of  blood  of  which  we  have 
spoken.  It  is  remarkable  that  a  part  of  this  blood  flowed  out 
from  the  intestines. 

Corrosive  poisons  might  doubtless  produce  in  the  stomach  the 
loss  of  substance,  analogous  to  that  caused  by  gangrene,  and 
possibly  the  follicular  ulcerations  of  the  stomach  may  assume  the 
gangrenous  aspect  often  found  in  aphthae  of  the  mouth.  It 
would  then  be  very  easy  to  distinguish  the  primitive  form  of  the 
ulcer,  notwithstanding  the  modification  produced  in  its  appear- 
ance by  gangrene. 

2d.  Gelatinous  softening. — M.  Cruveilhier  was  the  first  to 
describe  the  disorganization  of  the  mucous  membrane,  which  we 


ON   THE    DISEASES    OF    INFANTS.  263 

have  designated,  with  him,  by  the  title  of  gelatinous  softening. 
He  has  traced,  with  much  exactness,  the  assemblage  of  symp- 
toms which  accompany  this  disease.  M.  Baron  has  very  fre- 
quently observed  it  in  the  Hospice  des  Enfans  Trouves,  and  the 
symptoms,  according  to  him,  are  so  well  marked,  that  I  have  seen 
more  than  once  an  accurate  diagnosis  made  by  him  when  this 
disease  existed. 

I  propose  in  the  present  article,  to  exhibit,  as  well  as  I  am 
able,  the  characters  appertaining  to  this  disease,  and  to  point  out 
the  symptoms  with  the  greatest  possible  exactness. 

I  have  already  given  an  instance  of  gelatinous  softening  of  the 
stomach,  which  existed  at  the  same  time  with  muguet  and  folli- 
cular inflammation.  In  this  case  the  mucous  membrane  was  re- 
duced to  a  kind  of  thick  pulp,  resembling  jelly  in  consistence ; 
the  parietes  of  the  stomach  were  found  so  thin  and  fragile  that 
the  least  force  was  sufficient  to  perforate  it,  and  the  most  serious 
symptoms  existed  before  the  patient  sunk.  In  the  following 
cases  we  shall  see  the  same  affection  develop  itself  in  a  still  more 
evident  and  cognizable  manner. 

CASE  XXXVI. — Marie  Loumaison,  aged  seven  days,  entered 
the  infirmary  on  the  4th  of  February,  and  remained  there  twelve 
days  for  muguet  of  the  mouth,  which  disappeared  after  the  use  of  a 
mild  ptisan  and  emollient  gargles.  Yet  the  child  was  thin,  pale,  and 
very  feeble.  She  was  dismissed  on  the  fifteenth.  Notwithstanding 
she  was  put  to  nurse  on  the  18th  of  April,  she  continued  to  grow  thin 
and  pale,  and  exhibited,  particularly  at  night,  a  slight  turgescence 
of  the  legs  and  face.  On  the  21st  of  May  she  re-entered  the  infir- 
mary in  a  state  approximating  to  marasmus.  She  vomited,  besides 
the  drinks  and  aliments,  liquid  yellow  matters ;  the  face  expressed 
pain,  the  commissure  of  the  lips  was  almost  always  drawn  backward, 
and  vertical  wrinkles  were  formed  at  the  root  of  the  nose  ;  there  ex- 
isted no  diarrhoea  ;  there  was  a  slight  difficulty  of  respiration,  and 
sometimes  cough.  These  symptoms,  and  this  general  marasmus, 
continued  until  the  9th  of  May,  when  a  new  series  of  aflJections 
arose.  Several  points  of  muguet  showed  themselves  on  the  tongue, 
the  surface  of  which  was  red  and  dry  ;  the  vomitings,  besides  the 
drinks,  were  of  yellow  and  sometimes  green  substances  ;  the  expres- 
sion of  the  face  was  much  altered,  and  indicated  the  existence  of 
pain.     The  forehead  was  covered  with  a  number  of  transverse  wrin- 


264  ON   THE    DISEASES    OF    INFANTS. 

kles  ;  the  face  was  very  thin,  and  occasionally  livid ;  the  pulse  small 
and  slow ;  the  skin  dry  and  burning,  particularly  about  the  arms  ; 
all  these  symptoms  indicated  the  approaching  end  of  the  child  ;  and 
on  the  14th  of  May  she  died,  having  exhibited  throughout,  the  same 
symptoms.  The  treatment  consisted  of  ptisans  and  demulcent 
gargles.  The  examination  of  the  body  was  made  on  the  next 
day. 

Exterior. — A  general  paleness,  complete  marasmus,  infiltration  of 
the  lower  extremities,  and  distention  of  the  abdomen.  The  mucous 
membrane  of  the  mouth  was  covered  with  a  few  points  of  muguet. 
The  oesophagus  was  pale,  and  the  stomach  of  a  yellow  white  color 
in  its  whole  extent ;  but  at  the  greater  curvature  the  mucous  mem- 
brane was  very  much  tumefied  and  white,  and  so  soft  that  it  sepa- 
rated, on  touching  it,  in  the  form  of  a  pulp.  Upon  pressing  this 
membrane  there  exuded  between  the  fingers  a  serous  fluid,  which, 
on  being  received  on  a  watch-glass,  congealed  at  the  end  of  half  an 
hour,  having  the  same  appearance  and  gelatinous  consistence  as  that 
on  the  stomach.  The  other  coats  of  the  stomach  appeared  as  if  ma- 
cerated in  the  same  fluid,  and  were  ruptured  with  the  greatest  ease 
upon  the  least  force.  The  small  and  great  intestines  were  colorless 
throughout  their  whole  extent,  and  the  mucous  membrane,  without 
presenting  the  tumefaction  and  the  gelatinous  appearance  which  ex- 
isted in  the  stomach,  was  reduced  to  a  soft  pulpy  matter.  Some 
follicular  patches  situated  in  the  ileo-caecal  region,  were  tumefied 
and  of  a  slate  color.  The  foetal  openings  were  obliterated ;  the 
lungs  healthy,  and  the  brain  slightly  injected. 

We  see  in  this  case,  that  it  was  after  a  state  of  feebleness, 
caused  doubtless  by  a  phlegmasia  of  the  digestive  passages,  and 
particularly  of  the  stomach,  and  which  had  scarcely  left  any  traces 
of  the  active  stage,  that  this  gelatinous  softening  supervened : 
this  softening  being  always  characterized  by  a  serous  infiltration 
of  the  pulmonary  tissue,  and  in  the  parietes  of  the  stomach.  Is 
this  serous  accumulation  then  one  of  the  causes  of  this  gelati- 
nous appearance  and  softening  of  the  internal  membrane  of  this 
organ  ?  Does  there  exist  any  analogy  between  this  softening 
and  the  serous  infiltration  which  accompanies  gangrene  of  the 
mouth?  These  questions  are  natural,  for  they  arise  from  the 
appearance  and  form  of  the  alteration ;  let  us  see  whether  other 
cases  present  any  thing  analogous. 


ON    THE    DISEASES    OF    INFANTS.  265 

CASE  XXXVII. — Eugenie  Rouillard,  aged  four  days,  of  a  good 
constitution,  exhibiting,  over  the  whole  surface,  a  slight  icterous  tint, 
entered  the  infirmary  on  the  23d  of  August.  From  the  morning  of 
the  twenty-second,  she  had  passed  by  stool  a  large  quantity  of  liquid 
green  fceces,  and  had  also  vomited  a  quantity  of  green  fluid.  {Gum- 
med rice-water  j  milk  and  water.)  On  the  twenty-fourth,  the  physi- 
ognomy was  much  altered  and  the  face  pinched  ;  the  cry  was  fre- 
quent and  painful,  indicating  the  existence  of  much  distress;  from 
the  constant  motion  of  the  features,  and  of  the  globe  of  the  eye,  one 
would  have  been  led  to  believe  that  the  brain  was  aflfected,  of  which 
the  convulsive  movements  appeared  to  be  an  indication.  M.  Baron 
pronounced  it  to  be  a  case  of  gelatinous  softening  of  the  stomach. 
On  the  twenty-fifth,  the  vomitings  continued,  and  the  child  ejected, 
besides  drinks,  a  quantity  of  green  matter.  A  slight  inflammation  of 
the  left  palpebrae  appeared.  {Sweetened  barley-water,  emollient  col- 
lyrium.)  From  the  twenty-fifth  to  the  twenty-eighth,  the  same  state 
continued ;  emaciation  made  rapid  progress ;  the  face  expressed 
great  suflering,  but  the  general  agitation  was  succeeded  by  an  almost 
constant  prostration.  On  the  twenty-eighth,  all  the  buccal  mem- 
brane had  become  of  a  deep  red,  and  was  covered  with  muguet ;  the 
vomiting  continued,  but  the  diarrhoea  ceased.  There  .was  no  change 
until  the  6th  of  September.  From  that  time  to  the  twelfth,  she  gra- 
dually sunk,  after  constant  vomiting,  into  a  state  of  extreme  prostra- 
tion, the  pulse  being  throughout  feeble  and  small,  with  a  general 
discoloration  of  the  body  and  limbs.     On  that  day  she  died. 

On  examining  the  body,  some  remains  of  muguet  were  found  on 
the  tongue  and  along  the  oesophagus  ;  the  stomach,  at  its.  great  tube- 
rosity, presented  a  gelatinous  softening  of  the  mucous  membrane  to 
the  extent  of  two  inches,  which  appeared  pale  and  mixed  with  yel- 
low streaks,  and  was  so  tender  that  it  separated  upon  pouring  on  it 
the  small  stream  of  water  used  in  washing  it.  When  this  was  raised, 
the  muscular  coat — the  fibres  of  which  remained  whole — formed, 
with  the  serous  coat,  the  bottom  of  this  disorganization.  The  cir- 
cumference of  this  softening  was  surrounded  by  a  very  red  ring  or 
fold,  formed  of  the  mucous  coat,  which  at  this  place  was  not  softened, 
and  which,  when  cut,  appeared  as  if  infiltrated  with  bloody  serum. 
The  remainder  of  the  surface  of  the  stomach  presented  some  irregu- 
lar red  streaks,  and  in  certain  parts  a  very  intense  capillary  injec- 
tion. Red  streaks  were  observed  both  in  the  small  and  large  in- 
testines.    The  lungs,  heart,  and  brain  were  in  a  perfectly  healthy 

condition. 

34 


266  ON    THE    DISEASES    OF    INFANTS. 

Here  we  see  gelatinous  softening,  accompanied  by  traces  of  a 
very  severe  acute  inflammation.  The  circumstances  under 
which  this  case  was  observed,  and  that  which  we  just  before  de- 
scribed, were  altogether  opposite,  from  which  it  may  be  conclud- 
ed that  gelatinous  softening  is  not  more  the  result  of  an  acute 
than  of  a  chronic  inflammation.  We  have  also  observed  here  the 
accumulation  of  serum,  the  presence  of  which  contributed  much 
to  impart  to  the  disorganized  stomach  the  gelatinous  aspect  pre- 
sented by  the  mucous  membrane.  The  concretion  of  serum,  ex- 
pressed from  the  stomach  of  the  first  of  these  two  cases,  supports 
this  opinion.  The  disorganization  was  not  sufiiciently  advanced 
to  cause  a  perforation  of  the  organ,  as  existed  in  the  xxxivth  case^ 
where  the  softening  was  complicated  with  a  follicular  phlegma- 
sia. In  the  three  instances  reported  in  this  work,  and  in  four  others 
in.my  possession,  but  which  are  too  long  to  mention  here  in  de- 
tail, I  have  always  remarked  the  afiiux  of  serous  fluids  towards 
the  stomach  ;  we  have  reason  to  conclude  that  it  always  preced- 
ed the  softening ;  that  it  furnishes,  as  it  were,  the  materials  for 
this  softening ;  and  that  it  essentially  concurred  in  giving  the 
jelly-like  appearance  presented  by  the  macerated  and  softened 
mucous  membrane,  this  serum  being  mixed  with  the  blood 
drawn  thither  by  the  inflammatory  stimulus.  If  our  conjecture 
be  well  founded,  the  softening  ought  always  to  occur  towards  the 
most  dependent  part  of  the  organ,  for  it  is  in  that  part  that  the 
fluids  generally  accumulate ;  and  experience  proves  that  it  is  at 
the  great  tuberosity  of  the  stomach  that  this  disorganization  oc- 
curs. This  is  what  I  have  observed  in  the  history  of  the  seven 
cases  of  gelatinous  softening  in  my  possession,  and  M.  Baron  in- 
forms me  that  his  experience  has  always  confirmed  this  remark. 

What  inference  shall  be  drawn  from  the  preceding  facts  and 
considerations?  None  other  than  that  the  gelatinous  softness  of 
the  stomach  consists  in  a  disorganization  of  the  mucous  mem- 
brane of  this  viscus,  caused  by  an  acute  or  chronic  phlegmasia ; 
that  this  disorganization  is  characterized  by  an  accumulation  of 
serum  in  the  walls  of  this  organ,  the  intumescence  and  gelati- 
nous consistence  of  the  mucous  membrane  in  a  part  usually  cir- 
cumscribed, situated  more  frequently  in  the  greater  curvature, 
and  about  which  the  membrane  exhibits  more  or  less  evident 
traces  of  an  acute  or  chronic  phlegmasia ;  that  this  disorganiza- 


ON   THE    DISEASES    OP    INFANTS,  267 

tion  of  the  mucous  membrane  involving  that  of  the  other  coats, 
may  produce  the  spontaneous  and  fatal  perforations  which 
promptly  cause  the  death  of  the  patient ;  that  they  may  arise  not 
only  at  the  period  of  the  first  dentition,  as  in  the  greater  number 
of  cases  observed  by  M.  Cruveilhier,  but  also  in  very  young 
children,  instances  of  which  I  have  reported. 

The  softening  now  under  consideration  must  not  be  confound- 
ed with  another  kind  of  softening  which  does  not  usually  succeed 
an  acute  inflammation ;  the  nature  of  which  will  be  considered 
when  we  come  to  speak  of  all  the  phlegmasise  of  the  digestive 
tube. 

I  shall  not  attempt  to  discover  the  particular  cause  of  this  se- 
rous accumulation  which  accompanies  the  gelatinous  softening. 
Perhaps  I  ought  to  have  examined  the  state  of  the  blood  in  the 
surrounding  veins,  in  those  that  died  of  this  affection,  to  ascertain 
whether  the  course  of  the  blood  had  been  interrupted  by  concre- 
tions of  fibrin  —a  circumstance  which,  it  is  well  known,  some- 
times produces  a  serous  infiltration ;  but  this  investigation  did 
not  occur  to  me,  and  it  remains,  therefore,  a  deficiency  to  be  here- 
after supplied.  I  shall  not  attempt  to  mention  a  thousand  sup- 
positions which  the  imagination  here  suggests,  on  the  probable 
cause  of  this  disease,  for  I  do  not  record  in  this  work  any  other 
conclusions  than  those  drawn  from  positive  facts  ;  finding  it  im- 
possible to  explain  satisfactorily  the  immediate  cause  of  this  soft- 
ening, I  must  content  myself  with  pointing  out  all  the  circum- 
stances accompanying  it,  and  hasten  to  present,  at  one  view,  the 
symptoms  by  which  it  may  be  recognised  during  life. 

M.  Cruveilhier  has  already  traced  these  symptoms  with  great 
fidelity.  Some  of  the  particular  signs  which  he  has  pointed  out, 
will  be  recognised  in  the  description  I  shall  give. 

This  disease  usually  commences  with  symptoms  of  violent 
gastritis,  such  as  tension  and  pain  in  the  epigastric  region  ;  the 
substances  discharged  by  vomiting  are  not  only  the  milk  and 
drinks,  but  yellow  and  green  fluids,  occurring  either  immediate- 
ly or  a  long  time  after  eating  or  drinking.  There  sometimes  ex- 
ists a  diarrhoea,  varying  in  different  subjects.  It  will  return  af- 
ter having  ceased  for  one  or  two  days.  The  stools  are  often  green, 
like  the  matters  discharged  by  vomiting.     The  skin  is  cold  at  the 


268  ON    THE    DISEASES    OF    INFANTS. 

extremities ;  the  pulse  generally  irregular,  is,  however,  very  in- 
constant ;  the  face  continually  expresses  pain,  and  is  wrinkled, 
as  if  the  child  were  crying ;  the  cry  is  painful,  and  the  respiration 
jerking ;  and  the  general  restlessness  induces  a  belief  of  the  ex- 
istence of  a  cerebral  affection.  To  these  symptoms  succeed  a  ge- 
neral state  of  prostration  and  insensibility,  occasionally  disturbed 
by  the  return  of  pain,  producing,  from  time  to  time,  the  same 
restlessness  which  appeared  at  the  commencement  of  the  disease ; 
and  lastly,  at  the- end  of  six,  eight,  or  fifteen  days,  and  sometimes 
later,  the  patient  sinks,  wasted  by  wakefulness,  continual  vomit- 
ing, and  pain.  In  very  young  infants  scarcely  any  fever  is  man- 
ifested in  the  midst  of  this  disorder.  When  the  disease  is  chronic, 
the  progress  of  the  symptoms  is  slow. 

This  group  of  symptoms,  and  the  lesions  which  are  observed 
in  children  presenting  them,  give  to  the  disease  some  resem- 
blance to  spontaneous  perforations,  caused  by  a  partial  softening 
of  the  mucous  membrane  of  the  stomach,  a  long  time  since  ob- 
served by  Chaussier  in  lying-in  women,  and  which  MM.  Cloquet, 
Andral,  Louis,  and  several  others,  have  observed  in  adults  of  dif- 
ferent ages  and  sexes.  The  gelatinous  appearance  which  this 
softening  presents  in  infants,  arises  probably  from  the  facility 
with  which,  at  that  age,  the  cellular  tissue  which  enters  into  the 
composition  of  the  organs  is  infiltrated  with  serum. 

The  treatment  of  this  disease  is  included  in  that  of  gastritis  in 
general ;  but  it  ought  to  be  here  more  prompt  and  energetic,  for 
it  is  a  disease  of  frightful  .progress,  and  demands  our  closest  at- 
tention from  the  first  appearance  of  the  symptoms ;  we  shall  re- 
turn to  it  when  speaking,  of  the  treatment  of  gastritis. 

Treatment  of  gastritis. — One  of  the  first  indications  in  the 
treatment  of  this  disease,  is  to  suspend,  as  early  as  possible,  the 
functions  of  the  organ,  and,  of  course,  to  wean  the  child.  Stom- 
atitis, it  will  be  recollected,  whether  accompanied  or  not  with 
muguet,  is  easily  cured  by  applying  to  the  buccal  membrane  a 
small  pencil,  steeped  in  a  decoction  of  marshmallows.  The  child 
ought  then,  at  the  beginning  of  gastritis,  to  drink  a  weak  decoc- 
tion of  the  root  of  marshmallows,  sweetened  with  simple  syrup. 
Yet  it  should  be  mentioned  that  young  infants  do  not  bear  absti- 
nence well ;  therefore  during  the  time  of  separation  from  the 
breast,  the  child  ought  to  be  nourished  by  means  of  injections 


ON   THE    DISEASES   OP    INFANTS.  269 

made  with  a  decoction  of  rice  or  groats.  Injections  of  tepid  milk, 
particularly  if  they  be  sweetened,  may  produce  diarrhoea.  M. 
Guersent  has  observed  this,  and  he  often  employs  it  to  produce 
a  motion.  Having  myself  been  consulted  by  a  nurse  whose  child 
was  affected  with  acute  gastritis,  I  advised  her  to  wean  it  for 
some  time,  directing  also  the  administration  of  warm  milk  in  iur 
jection  for  nourishment.  It  was  followed  in  twenty-four  hours 
by  diarrhoea,  which  did  not  cease  until  the  use  of  the  injections 
was  suspended.  I  then  advised  the  white  decoction  of  Syden- 
ham ;  of  this  the  child  took  six  ounces  daily  at  three  different 
times.  This  fluid  was  entirely  absorbed ;  a  small  quantity  of  a 
weak  decoction  of  marshmallows  was  given  frequently,  and  in 
eight  days  the  symptoms  of  gastritis  disappeared. 

The  application  of  a  cataplasm  to  the  epigastric  region  ought 
not  to  be  omitted.  Leeches  to  this  part  do  not  generally  succeed, 
for  the  infant  is  uselessly  debilitated  by  their  use.  M,  Baron, 
who  has  often  made  the  attempt,  has,  at  last,  renounced  them. 
I  am  disposed  to  think,  however,  that  when  gastritis  presents 
very  serious  symptoms,  as  will  lead  us  to  apprehend  a  disorgan- 
ization of  the  stomach,  such  as  gangrene,  gelatinous  softening, 
etc.,  we  should  not  hesitate  about  applying  two  or  three  leeches 
to  the  epigastrium.  A  large  number  would  •  be  injurious.  I 
have  often  seen  robust  children  reduced  to  a  true  exsanguined 
state,  by  the  application  of  four  to  six  leeches  to  any  part  of  the 
body  whatever.  M.  Baron,  on  this  account,  does  not  generally 
resort  to  blood-letting  but  with  the  greatest  caution  in  young 
infants.*  ^ 

Derivations,  particularly  with  frictions  of  tartar  emetic  oint- 
ment on  the  epigastric  region,  may  be  employed  with  success  in 
chronic  gastritis  ;  but  when  evident  prostration  follows  these  vio- 
lent symptoms,  care  should  be  taken  not  to  use  tonics  and  stimu- 
lants— such  as  wine,  decoction  of  bark,  of  polygala,  serpentaria, 
etc.,  bearing  in  mind  that  the  prostration  is  often  caused  by  a 
great  disorganization  of  the  stomach,  as  has  been  demonstrated 
in  the  history  of  gelatinous  softening.  The  brown  substances 
often  vomited  by  new-born  children,  being  a  true  indication  of 
foUicular  ulcerations  of  the  stomach  ;  under  these  circumstances 

*  See  Appendix,  page  572. 


270  ON   THE    DISEASES    OP    INFANTS. 

we  should  refrain  from  giving  wine,  or  any  other  stimulant, 
with  a  view  to  strengthen  the  patient,  but  should  allow  it  to  suck 
in  small  quantities. 

The  general  treatment  which  I  have  described,  is  applicable  to 
every  modification  of  gastritis  ;  but  the  more  severe  the  symp- 
toms the  more  energetic  should  be  the  treatment. 

I  shall  terminate  the  history  of  inflammation  of  the  stomach 
with  one  important  observation.  It  is,  that  this  inflammation 
does  not  always  produce  symptoms  as  distinct  as  those  noted  in 
cases  reported  in  this  article.  There  are  some  instances  in  which 
the  affection  is  concealed  by  other  diseases ;  and  there  are  others 
where  only  a  part  of  the  symptoms  mentioned  are  seen ;  and 
again  it  will  sometimes  be  developed  in  so  latent  a  manner,  that 
it  is  almost  impossible  to  form  a  diagnosis  of  the  disease,  while  it 
is,  as  it  v/ere,  consuming  the  days  of  the  child.  I  shall  have  oc- 
casion to  refer  to  some  other  instances,  when  detailing  the  his- 
tory of  the  affections  of  other  organs.  I  shall  confine  myself 
here  to  the  observation  that  the  existence  of  an  affection  of  the 
digestive  organs  may  be  suspected,  however  slightly  apparent 
the  symptoms  may  be,  whenever  the  digestion  is  disturbed,  and 
the  child  is  gradually  wasting  away. 


Section  II. 

DISEASES   OF   THE    INTESTINAL    CANAL. 
§  I.    DeVeIoPMENT   of    THE    INTESTINAL    CANAL. The  firSt 

rudiments  of  the  intestinal  tube  in  the  human  embryo,  have  not 
as  yet  been  observed  with  sufficient  exactness  to  allow  of  the 
history  of  its  evolution  to  be  correctly  given.  It  is  rather  by 
analogy  and  induction,  than  by  direct  observation,  that  any  data 
upon  the  form  of  the  rudiments  of  the  intestines  can  be  estab- 
lished. Yet  the  works  of  those  celebrated  anatomists,  Meckel, 
Oken,  Wolf,  and  Tiedmann,  have  conducted  us  to  results,  which, 
if  they  are  not  incontestably  true,  are,  at  least,  very  probable. 

Thus  it  appears  to  be  proved  that  the  intestinal  tube,  at  first, 
consists  of  nothing  more  than  an  oblong  vesicle,  which,  elongat- 
ing at  the  same  time  both  superiorly  and  inferiorly,  forms  at 


ON  THE   DISEASES   OP   INFANTS.  271 

both  ends  an  imperforate  canal ;  but  which  soon  opens  both  at 
the  mouth  and  anus.  Other  anatomists  have  asserted  that  the 
intestinal  canal  was  formed  in  the  lateral  parts,  which,  by  the 
law  of  conjugation  established  by  Serres  in  organology,  advan- 
ced, as  it  were,  towards  each  other,  and  uniting  anteriorly  in  this 
manner,  completed  the  hollow  cylinder  of  the  intestines.  Ro- 
lando supposed  that  the  intestinal  canal  was  formed  in  separate 
portions,  and  afterwards  united. 

The  primitive  situation  of  the  intestinal  tube  has  also  given 
rise  to  numerous  conjectures.  Some  suppose  it  primitively  situ- 
ated against  the  vertebral  column,  others  at  the  anterior  part  of 
the  abdomen  at  the  base  of  the  umbilical  cord,  and  communicat- 
ing directly  with  the  umbilical  vesicle.  Velpeau  says  that  it  is 
enclosed  in  one  of  the  swellings  of  the  cord,  where  it  is  found 
surrounded  by  a  serous  fluid,  in  the  middle  of  which  is  seen  a 
a  small  quantity  of  yellow  matter.  Wolf  and  Meckel  say  that 
it  is  only  situated  near  the  umbilicus  when  it  has  undergone  a 
sort  of  bending  forward,  and  being  thus  curved,  it  forms  an  angle 
more  or  less  acute,  which  goes  to  the  base  of  the  cord  in  passing 
through  the  umbilical  opening.* 

I  shall  not  here  enter  into  the  examination  of  these  various 
opinions ;  but  shall  mention  only  an  essential  fact,  which  has 
some  bearing  on  the  pathology  of  new-born  children.  It  is  this, 
that  at  the  commencement  of  the  evolution  of  the  fa3tus,  the  an- 
terior part  of  the  abdomen  is  formed  of  a  kind  of  expansion  of 
the  base  of  the  cord,  and  that  the  intestinal  tube  adheres  poste- 
riorly to  the  vertebral  column,  spreading  forward  to  the  base  of 
the  cord,  where,  during  the  first  months,  the  intestinal  convolu- 
tions are  lodged.  This  fact,  which  is  merely  alluded  to  for  the 
present,  will  be  hereafter  considered  when  we  treat  of  the  sub- 
ject of  abdominal  hernias. 

Whatever  be  the  mode  by  which  the  intestinal  apparatus  as- 
sumes the  form  of  a  tube,  it  is  found,  at  the  third  or  fourth 
month,  perfectly  convoluted,  terminating  above  in  the  stomach, 
and  below  at  the  anus.    The  cavity  is,  at  this  time,  very  narrow, 

*  Further  details  may  be  found  in  Meckel's  Manual  of  general  and  descriptive  patho- 
logical anatomy,  v.  3.  Ollivier,  art.  Ocf  du  diet,  de  med.  Ph.  Beclard  Essai  sur 
Vembryologie,  Dissert,  inaug.    Paris,  1820. 


272  ON   THE    DISEASES    OF    INFANTS. 

and  the  younger  the  foetus,  the  shorter  is  the  intestinal  tube. 
From  the  sixth  to  the  eighth  month,  the  proportions  of  the  intes- 
tinal tube  are  nearly  analogous  to  those  of  its  different  constitu- 
ent parts  in  adults  ;  thus,  at  this  period,  the  convolutions  of  the 
small  intestines  are  very  numerous  ;  and  the  sacculi  of  the  large 
intestines  are  formed  about  the  fifth  month,  according  to  the  ob- 
servations of  Morgagni.  The  proportion  at  this  time,  between 
the  small  and  large  intestines,  is  as  eight  to  six.  These  observa- 
tions have  been  made  by  Haller,  Soemmering,  Wrisberg,  and 
Meckel.*  • 

Meckel  has  also  remarked,  that  towards  the  commencement  of 
the  third  month  several  longitudinal  folds  appear,  and  that  about 
the  end  of  the  fourth  month  the  villi  are  seen  under  the  form  of  a 
number  of  elevations.  About  the  seventh  month  the  valvulae 
conniventes  form ;  from  this  period  until  the  ninth  month,  the 
abdominal  circulation  is  very  active,  and  a  number  of  vascular 
ramifications  are  observed  to  appear,  first  on  the  mucous  mem- 
brane, and  afterwards  on  the  exterior  surface  of  the  intestines. 
From  this  habitual  congestion  of  the  digestive  tube,  there  results 
a  rose  color  of  the  internal  coat ;  which,  in  consequence  of  the 
engorgements  of  its  vessels,  is  easily  detached  from  the  serous 
membrane.  In  very  young  infants  the  muscular  fibres  are  but 
slightly  developed,  so  that  the  peritoneal  membrane  and  the  mu- 
cous membrane  are  in  close  approximation. t  The  caecum  begins 
to  appear  from  the  sixth  to  the  ninth  week.  It  assumes,  by  de- 
grees, its  form  and  relative  proportions.  Lastly,  the  great  omen- 
tum, which  before  the  second  month  had  not  appeared,  at  last  be-, 
gins  to  show  itself  on  the  loose  edges  of  the  stomach,  and  at  the 
period  of  birth  acquires  some  size ;  but  during  the  whole  of  the 
intra-uterine  life  remains  extremely  thin,  and  it  is  not  until  after 
birth,  that  it  becomes  thickened  by  the  development  of  the  adi- 
pose tissue,  which  increases  in  growth  more  or  less,  according  to 
the  natural  tendency  of  the  individual.  I  shall  not  here  speak 
of  the  glandular  or  lymphatic  apparatus,  which  forms  an  appen- 
dage to  the  digestive  tube,  because  they  will  be  considered  in 
another  place. 

*  Ph.  Beclard,  Dissert,  inaug.  p.  79. 

t  Ch.  Billard,  De  la  membrane  muqueuse  gastro-inteatinal,  dan»  Petat  sain  et 
dans  Vetat  inflam.     Paris,  1826. 


ON    THE    DISEASES   OP    INTANTS.  273 

While  the  intestinal  tube  undergoes  these  changes,  and  the 
different  portions  constituting  it  form  a  union  by  which  the  ca- 
nal is  to  be  completed,  and  in  which  the  organs,  together  with 
the  internal  membrane  itself,  were  pouring  their  secretions  for 
lubrication  and  perhaps  for  nourishment,  a  series  of  phenomena 
constituting  a  species  of  intra-uterine  digestion,  has  commenced, 
the  duration  of  which  is  about  two-thirds  of  the  fcEtal  life,  and 
which  terminates  at  birth.  This  digestion  of  matters  spread  or 
secreted  throughout  the  digestive  passages,  bears  some  resem- 
blance, in  reference  to  its  duration,  to  that  of  hybernating  ani- 
mals. 

If  this  be  so,  the  intestinal  tube  of  a  young  infant  just  born 
will,  on  examination,  exhibit  all  the  anatomical  phenomena 
which  the  digestive  apparatus  of  an  adult  presents  who  had  died 
during  digestion.  This  is,  in  truth,  what  the  digestive  organs  of 
new-born  children  exhibit.  Let  us  stop,  then,  for  a  moment,  to 
consider — 1st,  The  form  and  aspect  of  the  organs  of  digestion  in 
a  new-born  infant ;  2dly,  The  nature  and  physical  qualities  of 
the  matters  contained  in  the  digestive  tube ;  3dly,  The  manner 
in  which  the  first  alvine  evacuations  are  made,  and  the  phenom- 
ena which  attend  it.  All  this  is  of  importance  to  know ;  for  to 
appreciate  properly  the  various  pathological  conditions  of  the  in- 
testinal tube  of  young  infants,  it  is  absolutely  necessary  to  be  fa- 
miliar with  the  true  characters  of  this  organ  in  a  state  of  health. 

The  duodenum  has  a  rosy  appearance,  which  is  continued  to 
the  jejunum,  but  is  less  remarlcable  in  the  ileon.  The  jejunum  has 
some  traces  of  the  valvulae  conniventes  ;  the  villi  are  equally  de- 
veloped, and  very  often  in  the  jejunum  are  found  some  separate 
mucous  follicles,  about  the  size  of  the  head  of  a  pin,  and  almost 
always  white  ;  some  foUicular  plexuses,  slightly  projecting,  also 
white,  and  often  with  a  little  black  point  on  the  top,  as  observed 
in  adults,  are  met  with  in  the  ileon.  The  ileo-caecal  valve  is  a 
little  projecting,  and  the  opening  which  it  surrounds,  extremely 
small.  In  most  children  it  would  be  difficult  to  pass  even  a  crow- 
quill  ;  at  this  age  it  prevents  the  regurgitation  of  substances,  and 
even  gas,  from  the  great  intestines  to  the  small,  but  allows  a 
free  passage  for  the  contents  of  the  small  intestines  into  the 
large.     This  can  easily  be  proved  by  passing  a  current  of  water 

through  one  or  the  other  of  the  extremities  of  the  digestive  tube  j 

35 


274  ON   THE    DISEASES  OF    INFANTS. 

in  the  one  direction  the  water  passes  freely,  while  in  the  other  it 
will  meet  with  an  insurmountable  obstacle.  Neither  do  the  cae- 
cum nor  colon  as  yet  present  their  depressions  and  prominences 
in  as  distinct  a  manner  as  afterwards,  or  as  they  appear  in  adults. 

After  birth  the  internal  membrane  of  the  digestive  passages 
gradually  loses  its  habitual  color,  and  becomes  of  a  milky  white, 
and  continues  for  some  time  floculent.  During  the  whole  of  the 
first  year  it  is  remarkable  for  this  appearance,  and  for  the  abun- 
dant secretion  of  mucosity. 

The  matters  contained  in  the  intestinal  canal  of  a  young  in- 
fant vary  with  reference  to  their  color  and  consistence.  Gene- 
rally there  is  found  in  the  duodenum  and  jejunum,  thick  mucous 
substances  of  a  white  color,  adhering  to  the  walls  of  the  intes- 
tines, sometimes  collected  together  in  certain  parts,  and  some- 
times spread  over  them.  They  are  often  colored  yellow,  owing 
probably  to  the  bile ;  and  there  are  also  found  balls  or  small 
masses  of  a  green  color,  which  is  observed  in  the  intestines  a 
long  time  after  the  expulsion  of  the  meconium.  I  have  found 
them  in  a  child  eight  or  ten  days  old  ;  it  would  appear  that  they 
did  not  possess  any  irritating  property,  for  their  contact  never 
produces  inflammation  of  the  mucous  membrane.  It  is  very 
common  also  to  find  about  the  ileo-csecal  region,  an  accumula- 
tion of  yellow  and  frothy  liquid ;  the  large  intestines  are  always 
filled  with  meconium,  of  the  consistence  of  pitch,  and  of  a  deep 
green  color — a  circumstance  noted  by  all  authors. 

Such  are,  in  the  ordinary  state,  the  varieties  of  aspect  present- 
ed by  the  matters  contained  in  the  intestines.  The  meconium — 
that  is  to  say,  the  thick,  pitchy,  green  substance,  which  may  be 
regarded  as  the  result  of  foetal  digestion,  and  which  may  also  be 
compared  to  the  foeces  in  the  colon  of  an  adult — does  not  gene- 
rally assume  the  physical  characters  which  have  been  assigned 
to  it,  until  it  has  arrived  at  the  large  intestines ;  and  when  it  is 
found  at  the  commencement  of  the  small  intestines,  and  even  in 
the  stomach,  it  is  because  it  has  ascended  thither  by  a  true  anti- 
peristaltic movement. 

Yet  there  have  been  very  singular  aberrations  observed  with 
respect  to  this  general  rule.  Such,  for  example,  is  the  extraordi- 
nary case  of  meconium  filling  the  imperforate  oesophagus  of  an 
acephalous  child;,  the  account  of  which  has  been  given  by  M. 


ON    THE    DISEASES    OP    INFANTS.  275 

Lallemand,  and  of  which  we  have  before  spoken.  Are  we  not 
led  to  believe,  after  this  curious  fact,  that  the  meconium  formed 
by  the  waters  of  the  amnios  which  had  been  swallowed,  and  by 
the  mucus  secreted  on  the  surface  of  the  intestines,  acquired 
physical  properties  in  consequence  of  its  prolonged  contact  with 
the  digestive  tube  ?  And  if  it  be  met  with  in  the  colon,  is  it  not 
because  this  portion  of  the  intestines  receives  generally  the  first 
of  the  intestinal  matters,  and  which  are  found  abounding  in  this 
part  in  proportion  as  they  are  introduced,  or  have  been  secreted 
in  the  intestines  ?  This  view  of  the  subject  accords  with  the 
opinion  of  physiologists,  who  think  that  the  nutrition  of  the  foe- 
tus is  carried  on  not  only  by  means  of  the  placentary  circula- 
tion, but  also  by  the  liquor  amnii.*  But  let  us  return  to  the  sub- 
ject, and  to  the  description  of  the  varieties  of  aspect,  which  the 
healthy  state  of  the  mucous  membrane  of  a  young  child  presents. 

When  all  the  liquid  parts  of  the  intestinal  tube  are  removed, 
there  still  remains  a  layer  of  thick  mucus  adhering  to  the  inter- 
nal surface  of  the  canal,  forming  on  it  a  kind  of  plastering.  This 
layer  may  be  raised  with  the  nail,  under  the  form  of  a  pellicle, 
resembling,  to  a  superficial  observer,  portions  of  the  mucous 
membrane  itself 

It  is  probably  this  layer  of  mucus  that  certain  practitioners  re- 
gard as  vitiated  matters,  or  saburra,  for  the  expulsion  of  which 
they  have  recommended  purgatives  from  the  time  of  birth. 

But  whether  this  mucus  be  for  no  other  object  than  protection 
of  the  mucous  membrane  when  exposed  to  the  contact  of  unac- 
customed aliments,  or  whether  it  be  a  simple  deposit  of  a  fluid 
contained  for  a  long  time  in  the  alimentary  canal,  attaching  it- 
self, without  any  use,  to  its  surface — it  never  remains  there  but 
for  a  short  time,  and  detaches  itself,  without  the  assistance  of  any 
purgative,  by  a  kind  of  natural  exfoliation. 

This  exfoliation  occurs  in  very  thin  lamellae,  which,  being 
rolled  together,  form  the  small,  white  floculi  so  frequently  met 
with  in  the  stools  of  young  children  ;  and  where  the  surface  of 
the  duodenum  or  jejunum  is  colored  with  bile,  it  is  this  layer 
of  mucus  that  is  colored,  so  that,  in  removing  it,  the  color  also 
disappears  from  the  intestine. 

*  Lobstein,  Essai  sur  la  nutrition  du foetus.     Strasburg,  1802. 


276  ON  THE  DISEASES  OF  INFANTS. 

I  will  here  stop  to  make  an  observation  worthy  of  attention. 
It  is  well  known  that  the  meconium  always  colors  the  mucous 
membrane  green,  with  which  it  is  contact.  But  it  often  hap- 
pens, when  it  is  evacuated,  that  it  carries  with  it  some  pellicular 
fragments  of  the  mucous  coating  of  which  I  have  spoken,  by 
which  species  of  exfoliation  the  colon  loses  its  green  color.  If 
the  meconium  be  very  liquid,  it  is  quickly  expelled,  leaving  after 
it  the  green  coloring ;  but  it  sometimes  passes  off  by  little  at  a 
time,  and  then  the  colon  presents,  alternately,  irregular  patches  of 
green  and  white.  This  can  easily  be  ascertained  by  raising  the 
meconium  gently  from  the  surface  of  the  colon  with  the  back  of 
a  scalpel.  The  membranous  pulp,  and  the  fragments  of  mucus, 
together  with  other  intestinal  matters,  will  be  seen  to  be  raised 
at  the  same  time,  leaving  the  internal  membrane  colorless. 

As  soon  as  the  child  has  commenced  a  new  kind  of  alimenta- 
tion, the  contents  of  the  intestines  change  their  appearance,  the 
phenomena  of  digestion  becoming,  with  respect  to  the  manner  in 
which  it  is  performed,  analogous  to  what  it  will  be  during  the 
remainder  of  life.  A  great  deal  of  importance  is  usually  attach- 
ed to  the  first  discharges  from  the  bowels  ;  and  nurses  are  eager 
to  administer  to  a  child  just  born,  some  mild  purgative,  under  the 
fear  of  retaining,  for  too  long  a  time,  a  substance  which  absurd 
prejudices  have  induced  them  to  regard  as  irritating,  and  as  ca- 
pable of  exercising  a  serious  effect  on  the  system.  I  am  far  from 
entertaining  any  such  ideas,  for  I  can  see  in  the  meconium  no 
irritating  or  chymical  property  ;  but  I  conceive  that  a  prolonged 
retention  of  this  foecal  matter  may  produce,  if  it  be  not  evacuat 
ed,  effects  analogous  to  those  which  obstinate  costiveness  produ- 
ces in  adults.  Without,  therefore,  establishing  any  general  rule 
for  the  administration  of  laxative  drinks,  I  think  it  rational  to  re- 
commend a  small  quantity  of  syrup  of  rhubarb,  or  an  injection 
composed  of  warm  water  and  olive  oil,  to  those  infants  who,  with- 
out having  any  malformation,  are  slow  in  passing  the  meconium. 

§  II.  Malformations  of  the  intestinal  tube. — Some- 
times a  greater  or  less  portion  of  the  intestinal  tube  is  deficient  in 
acephalous  children.  Often  but  a  portion  of  the  small  intes- 
tines is  found  with  the  large,  or  the  large  intestine  alone.  The 
other  primitive  malformations  may  be  referred  to  division,  obli- 


ON   THE    DISEASES   OP    INFANTS.  277 

teration,  dilatation,  and  strictures  of  the  digestive  tube  in  some 
of  its  parts. 

Division,  or  interruption  of  the  intestinal  canal,  has  been  no- 
ticed in  different  parts,  but  particularly  in  the  small  intestines. 
Dr.  A.  Schaefer,  in  publishing  a  case  of  division  of  the  intestinal 
canal  into  several  portions,  has  enumerated  almost  all  the  analo- 
gous cases  furnished  by  authors,  and  has  added  to  this  disserta- 
tion several  judicious  reflections  upon  the  possible  causes  of  this 
malformation.*  I  shall  not  follow  him  in  all  the  details  of  his 
memoir,  nor  seek  to  demonstrate  whether  these  interruptions  of 
the  digestive  tube  result  from  the  principle  of  the  formation  of 
the  tube  in  distinct  portions  ;  but  will  keep  myself  to  the  object 
of  this  work,  and  endeavor  to  acquire  a  correct  knowledge  of  the 
symptoms  which  a  child,  affected  with  this  infirmity,  exhibits. 

The  child  which  forms  the  subject  of  M.  Schaefer's  memoir, 
was  born  at  Wurzbourg,  in  December,  1824,  at  the  full  time. 
Considered  externally,  it  was  well  formed,  but  slightly  jaundiced. 
It  complained  much,  and  voided  neither  excrement,  meconium, 
nor  urine.  It  swallowed  the  liquids  which  were  given,  but  soon 
vomited  them.  The  vomitings  consisted  of  brown  liquid,  re- 
sembling the  meconium ;  the  child,  after  becoming  much  emaci- 
ated, died  on  the  seventh  day  after  birth. 

Upon  examining  the  body,  all  the  organs  were  found  healthy 
except  the  intestinal  tube,  which  presented  the  following  appear- 
ances. The  stomach  was  situated  more  vertically  than  is  usual 
afthis  age,  and  more  pushed  back  in  the  left  hypogastric  region, 
and  was  filled  with  liquids  which  had  been  swallowed  by  the 
child.  The  duodenum  was  so  much  distended  that  it  exceeded  in 
volume  that  of  an  adult.  The  third  part  of  this  intestine,  after 
having  passed  through  the  mesocolon,  terminated  in  a  cul-de- 
sac  ;  the  pancreatic  duct,  and  the  common  duct  of  the  liver, 
opened  into  the  duodenum  in  the  usual  manner ;  the  whole  of 
the  intestine  was  full  of  a  brown  fluid.  The  rest  of  the  intesti- 
nal canal  was  very  narrow,  and  its  cavity  contained  a  small 
quantity"  of  white,  viscid,  albuminous  matter,  which,  in  the  ileon, 
appeared  to  be  reduced  to  little  balls ;  the  duodenum  was  an 
inch  and  a  half  wide,  and  nine  inches  and  ten  lines  in  breadth. 

*  See  Journal  complement,  du  diet,  des  sciences  med.,  t.  24,  p.  58. 


278  ON   THE    DISEASES   OP    INFANTS. 

The  remainder  of  the  small  intestines  was  thirty-four  inches 
long,  an-d  two  lines  and  a  half  broad,  and  the  large  twelve  inches 
six  lines  long,  and  two  lines  and  a  half  wide.  The  length  of 
the  caecum  was  two  lines,  and  that  of  its  appendix  twenty-one 
lines. 

I  met  with  an  analogous  case  in  the  Hospice  des  Enfans 
Trouves,  the  history  of  which  I  will  give  in  detail. 

CASE  XXXVIII.— Theophile  Taillebois,  a  male  child,  aged  one 
day,  of  a  feeble  constitution,  entered  the  infirmary  on  the  3d  of 
April,  1826.  The  integuments  of  this  child  were  slightly  colored ; 
the  circulation  was  slow,  and  the  motions  feeble.  On  the  fourth, 
he  vomited  the  milk  and  sweetened  water  that  had  been  given  ;  the 
respiration  was  difficult ;  the  cry  painful,  and  smothered ;  the  puis© 
very  slow.  The  meconium  had  not  passed  since  his  birth  ;  yet  the 
abdomen  was  but  slightly  swelled.  On  the  5th  of  April,  he  vomit- 
ed an  abundance  of  yellow  fluid,  and  on  the  sixth  he  died. 

The  exterior  of  the  body  presented  but  a  slight  icterous  appear- 
ance. The  mouth,  oesophagus,  and  stomach  were  healthy  ;  the  duo- 
denum was  very  much  dilated  to  the  end  of  its  third  curvature.  Its 
calibre  was  nearly  an  inch  in  diameter  ;  it  terminated  suddenly  in  a 
cul-de-sac,  from  which  the  remainder  of  the  intestinal  canal  was 
continued,  the  calibre  of  which  was  extremely  small.  The  serous 
membrane  of  the  duodenum  was  continuous  with  that  of  the  jeju- 
num ;  but  at  the  interior  there  was  a  complete  obliteration,  without 
any  trace  of  constriction  of  the  mucous  membrane,  which  terminat- 
ed like  the  crown  of  a  hat.  This  intestine  was  distended  with  a 
large  quantity  of  yellow,  frothy  liquid.  It  had  not  the  pitchy  con- 
sistence nor  the  green  color  of  the  meconium.  The  remainder  of 
the  intestinal  canal,  the  calibre  of  which  would  not  allow  of  the  pas- 
sage of  a  female  catheter,  did  not  contain  any  thing  but  a  very  small 
quantity  of  white  mucus,  adherent  to  the  walls  of  the  intestine.  The 
large  intestines,  the  size  of  which  was  a  little  more  than  natural, 
contained  also  but  a  small  quantity  of  the  same  kind  of  mucus. 
There  was  found  in  them  no  trace  of  the  meconium,  and  the  mucous 
membrane  was  very  white. 

The  two  lungs  were  gorged  with  blood,  particularly  at  their  poste- 
rior border  ;  the  foetal  openings  were  still  unclosed  ;  the  brain  was  a 
little  injected. 

In  these  two  cases  we  have  seen  that  the  children  did  not  pass 


ON   THE    DISEASES   OP    INFANTS,  279 

any  meconium ;  that  they,  at  first,  vomited  the  drinks  given,  af- 
terwards yellow  and  frothy  matters,  which  did  not  possess  the 
proper  characters  of  the  meconium.  Such  are  the  most  marked 
symptoms  by  which  we  will  be  enabled  to  recognise  the  exist- 
ence of  an  obliteration  of  the  small  intestines.  We  ought  to  note 
particularly  the  absence  of  green  matters  in  the  remainder  of  the 
intestines ;  below  the  obliteration,  the  walls  were  only  covered 
with  the  mucus  which  had  been  secreted.  This  circumstance 
proves  to  us  that  the  green  matters  with  which  the  large  intes- 
tines are  usually  filled  in  young  infants,  are  really,  as  I  before 
observed,  the  product  of  the  fostal  digestion,  the  aliments  or  ma- 
terials of  which  are,  without  doubt,  the  waters  of  the  amnios 
swallowed  by  the  child,  and  the  product  of  the  pancreatic,  biliary, 
and  mucous  secretions. 

Dr.  Schaefer  remarks  that  the  abnormal  cases  of  division  in 
the  intestinal  canal,  reported  by  authors,  may  be  classed  under 
three  heads — 1st,  The  intestinal  canal  may  be  only  constricted 
in  several  places ;  2dly,  It  may  be  divided  into  several  parts  by 
the  internal  membranes ;  3dly,  It  may  be  divided  into  several 
parts  entirely  separated,  the  one  from  the  other. 

All  these  malformations,  whatever  be  the  point  where  they 
exist,  must  be  regarded  as  mortal,  the  child  living  at  most  but 
two  days. 

Among  the  malformations  of  the  intestinal  tube,  ought  to  be 
arranged  the  diverticuli  which  are  observed  in  it,  and  which  are 
usually  situated  in  the  small  intestines.  They  appear  to  be  the 
result  of  the  adhesions  existing  primarily  between  the  intestines 
and  the  umbilical  vesicle ;  they  are  rarely  productive  of  any  par- 
ticular disturbance,  and  are  no  obstacle  to  the  establishment 
of  the  digestive  functions. 

The  inferior  extremity  of  the  intestinal  tube  sometimes  pre- 
sents a  complete  obliteration,  which  results  from  the  imperfora- 
tion  of  the  skin  at  the  anus,  or  the  absence  of  the  rectum  to  a 
greater  or  less  extent. 

The  rectum  then  terminates  in  a  cul-de-sac,  and  presents  a 
pouch,  terminating  inferiorly  by  a  circular  corrugation  of  its 
membranes.  It  is  not  yet,  in  a  young  infant,  much  dilated,  but  it 
soon  becomes  more  so,  in  proportion  as  the  intestinal  matters^ 
the  evacuation  of  which  is  impossible,  accumulate  in  its  cavity »- 


280  ON    THE    DISEASES    OF    INFANTS. 

When  one  part  of  the  rectum  is  deficient,  the  intestine  terminates 
and  adheres  to  the  anterior  part  of  the  sacrum,  to  which  it  be- 
comes more  or  less  attached ;  if  the  whole  of  the  rectum  be  ab- 
sent, the  extremity  of  the  colon  terminates  near  the  sacro-verte- 
bral  angle  by  a  cul-de-sac,  which  generally  adheres  to  the  supe- 
rior extremity  of  the  sacrum. 

The  imperforation  or  absence  of  the  rectum  does  not  always 
coexist  with  the  imperforation  of  the  anus.  The  orifice  some- 
times exists  when  the  rectum  is  obliterated.  This  circumstance 
is  the  more  serious,  as  the  normal  state  of  the  anal  orifice  does 
not  lead  to  the  suspicion  of  the  existence  of  the  occlusion,  thus 
leaving  the  accoucheur  in  a  fatal  security. 

The  study  of  the  symptoms  which  result  from  the  imperfora- 
tion of  the  anus,  may  be  here  of  some  utility ;  it  will  enable  us 
also  to  know  the  proper  signs  of  ileus,  or  the  symptoms  of  an  in- 
terruption of  the  course  of  intestinal  substances  in  a  young  in- 
fant. 

CASE  XXXIX. — Congenital  imperforation  of  the  anus. — Le- 
blond,  aged  one  day,  of  a  robust  constitution,  entered  the  infirmary 
of  the  Hospice  des  Enfans  Trouves  on  the  10th  of  July.  To  the 
night  of  the  eleventh,  he  had  passed  no  meconium  ;  yet  the  orifice 
of  the  anus  appeared  free ;  the  abdomen  had  become  swollen  and 
very  painful ;  the  respiration  was  difiicult ;  the  extremities  cold ; 
the  pulse  small ;  the  cries  were  without  intermission.  Towards 
evening,  the  child,  after  having  thrown  up  a  quantity  of  yellow  mu- 
cus, vomited  the  meconium. 

It  was  placed  in  a  bath  for  half  an  hour  without  having  any  evacu- 
ation. The  anal  opening  appeared  to  exist  externally,  and  a  cathe- 
ter could  be  introduced  to  the  depth  of  one  inch,  but  then  met  with 
an  insurmountable  resistance.  I  caused  a  suppository  of  soap  to  be 
passed  in  the  rectum,  and  let  it  remain  half  an  hour  without  any  eva- 
cuation. I  then  passed  a  bistoury,  the  point  of  which  was  directed 
by  means  of  a  grooved  probe,  in  the  direction  of  the  sacrum  ;  the 
edge  of  the  instrument  turned  backward,  and  the  back  of  it  forward. 
The  feeling  that  the  resistance  was  overcome,  indicated  that  the 
perforation  had  been  made.  I  withdrew  the  instrument,  the  point  of 
which  was  covered  with  meconium ;  a  small  quantity  of  blood 
flowed.  An  injection  was  then  administered,  which  was  soon  re- 
turned, bringing  with  it  some  grumous  blood.     The  child  was  again 


ON   THE    DISEASES   OP   INFANTS.  281 

placed  in  the  bath,  without  experiencing  any  relief.  The  cry  be- 
came more  feeble  ;  the  abdomen  swelled  more  and  more  ;  the  respi- 
ration was  quick  and  suffocating.  Death  took  place  about  the  mid- 
dle of  the  night. 

Post  mortem  examination.— Month  and  oesophagus  healthy  ;  the 
stomach  contained  some  meconium ;  it  was  also  found  in  the  small 
intestines,  which  were  distended  with  gas.  The  large  intestines 
were  considerably  dilated  by  thick  meconium  ;  the  dilatation  com- 
menced at  the  caecum.  The  rectum  terminated  by  a  cul-de-sac,  the 
extremity  of  which  was  corrugated ;  it  adhered  to  the  neck  of  the 
bladder,  and  did  not  descend  to  the  anal  orifice  in  the  skin.  The  in- 
cision made  in  the  cul-de-sac  by  the  bistoury  was  found  filled  with  a 
recently  formed  clot  of  blood,  which  seemed  to  have  resulted  from  a 
hemorrhage  from  the  hemorrhoidal  arteries.  All  the  organs  of  the 
abdomen  were  perfectly  healthy. 

The  lungs  were  gorged  with  blood  at  their  posterior  border  ;  the 
foetal  openings  were  free ;  the  sinuses  of  the  cranium  were  filled 
with  blood. 

It  is  probable  that  the  blood  which  flowed  from  the  edges  of 
the  incision,  immediately  obliterated  the  artificial  opening,  thus 
obstructing  the  evacuation  of  the  contents  of  the  intestines.  Per- 
haps  this  obstruction  might  have  been  overcome  by  the  introduc- 
tion of  a  gum  elastic  catheter,  with  the  assistance  of  which  tepid 
water  might  have  been  injected  into  the  rectum  to  dilute  the 
contents,  and  thus  render  their  ejection  more  easy.  In  the  case 
of  an  imperforate  anus,  an  opening  should  be  made  as  early  as 
possible,  for  by  delaying  the  operation  it  may  not  prove  so  suc- 
cessful, whatever  may  be,  at  first,  the  apparent  good  result. 

CASE  XL. — Imperf oration  of  the  anus,  enteritis. — Grenel, 
aged  two  days,  entered  by  the  "Creche"  on  the  9th  of  March.  This 
child  had  passed  no  meconium  since  birth ;  the  abdomen  was  tume- 
fied and  very  painful,  for  the  child  cried,  and  the  face  became  pinch- 
ed whenever  the  abdomen  was  touched.  The  course  of  the  colon 
could  be  felt  through  the  parietes  of  the  abdomen.  He  vomited  green 
substances  ;  the  cry  was  feeble  ;  skin  cold  ;  and  the  circulation  very 
slow.  The  anus  was  imperforate,  although  there  existed  the  ap- 
pearance of  its  orifice  at  the  perinoeum.  I  passed  through,  a  sharp- 
pointed  bistoury,  being  careful  to  turn  the  back  towards  the  bladder, 

36 


282  ON    THE    DISEASES    OF    INFANTS. 

and  after  having  made  the  incision,  I  enlarged  it  in  a  backward  di- 
rection. A  large  quantity  ofmeconium  immediately  issued  from  the 
opening ;  the  swelling  of  the  abdomen  immediately  subsided,  and  the 
pain  apparently  ceased,  for  the  child  stopped  crying,  and  the  face  no 
longer  exhibited  the  expression  of  pain.  He  was  immersed  for  half 
an  hour  in  a  bath  of  marshmallows ;  but  notwithstanding  all  these 
precautions,  the  vomiting  continued,  and  he  died  at  night. 

On  examining  the  body,  a  passive  congestion  of  the  pharynx  was 
found,  and  on  the  mucous  membrane  of  the  stomach  several  patches 
of  a  vivid  red,  together  with  a  universal  redness  and  tumefaction  of 
the  inner  membrane  of  the  small  intestines  ;  the  muciparous  follicles 
were  very  numerous  in  the  large  intestines  ;  the  circumference  of 
each  of  these  follicles  was  surrounded  by  a  red  circle ;  the  rectum 
was  continued  to  the  perinceum,  where  it  was  only  closed  by  a  sim- 
gle  membrane.  A  large  quantity  of  meconium  was  found  in  the 
large  intestines.  The  remainder  of  the  intestinal  tube  contained 
some  yellow  adhesive  matters.  The  circulatory  and  cerebral  sys- 
tems were  healthy. 

It  is  evident  that  had  it  not  been  for  the  gastro-enteritis,  this 
child  would  have  been  cured  by  the  simple  operation  that  was 
performed. 

Instead  of  presenting  a  simple  imperforation,  as  in  the  case 
just  considered,  the  rectum  is  sometimes  imperforate  in  conse- 
quence of  a  union  with  the  surrounding  parts,  especially  with 
the  bladder.  A  very  curious  case  of  this  unnatural  union  of  the 
rectum  with  the  bladder  is  found  in  Commeritationes  societatis 
regicc  scientiarum  Gottingensis,  ad  annum  1778. 

The  rectum  has  been  observed  to  open  into  the  vagina,*  and 
also  into  the  bladder.f  These  deviations  are  less  dangerous  or 
less  quickly  fatal  than  a  complete  imperforation  of  the  anus ;  but 
they  are  still  of  a  very  serious  nature,  as  they  condemn  the  in- 
dividual to  a  disgusting  infirmity. 

When  a  child  is  born  with  an  imperforate  anus,  the  operation 
for  the  restoration  of  the  passage  must  be  performed  immediate- 
ly, and  it  ought  to  differ  according  to  the  point  at  which  the  ob- 
struction is  found  to  exist.     Sabatier  has  given,  in  his  treatise 

♦  Journal  de  med.,  chirurg.  et  pharm.  t.  6,  p.  128. 
+  Idem,  1. 16,  p.  107. 


ON   THE    DISEASES   OP    INFANTS.  283 

«c?e  la  medicine  operatoire^^^  some  excellent  precepts  on  this 
subject. 

If  the  imperforation  consist  in  a  simple  occlusion  situated  near 
the  anus,  which  will  be  known  by  a  general  tension  of  the  ab- 
domen, and  a  feeling  of  fluctuation  experienced  at  the  rectum, 
which  is  distended  with  meconium,  rendered  more  manifest 
during  the  crying  of  the  child,  several  crucial  incisions  should 
be  made  with  a  pointed  bistoury  in  the  membrane  obstructing 
the  rectum ;  the  borders  of  this  incision  will  not  reunite,  in  con- 
sequence of  the  continual  passage  of  the  foeces ;  if  the  opening 
be  too  narrow,  it  may  be  widened  by  a  bistoury.  Care  should 
be  used  to  prevent  cutting  the  whole  of  the  sphincter  through, 
for  Sabatier  has  seen,  in  an  occurrence  of  this  kind,  where  the 
discharges  were  involuntary  from  this  cause :  it  occurred  in  an 
infant  that  died  some  months  after  the  operation,  from  some 
other  cause.  When  the  imperforation  is  situated  higher  up,  it 
is  advised  to  pass  a  trocar,  the  canula  of  which  is  grooved  for 
the  direction  of  the  bistoury,  in  the  direction  of  the  rectum.  A 
straight  bistoury  may  also  be  used,  as  was  done  by  Petit  in  a 
case  where  the  operation  was  followed  by  a  successful  result. 
and  the  matters  flowed  out  freely  during  two  months,  the  time 
that  the  child  lived.* 

If  the  rectum  be  deficient,tof  which  we  may  be  confident 
when  we  are  unable  to  feel  any  signs  of  fluctuation  in  the  peri- 
neum, it  will  then  be  necessary  to  make  an  artificial  anus  in  the 
lower  part  of  the  abdomen.  Littre  advises  an  incision  to  be 
made  in  the  integuments  near  one  of  the  groins,  and  then  to 
search  for  a  portion  of  the  intestine,  and  attach  it  by  sutures  to 
the  incision,  and  thus  establish  an  artificial  anus.  Duret  has 
performed  this  operation  with  success  in  the  left  iliac  region. 
The  colon  was  adjusted  to  the  lips  of  the  wound  by  means  of  a 
waxed  thread  passed  behind  it,  a  longitudinal  incision  made,  and 
an  artificial  anus  was  established  on  the  seventh  day  after  the 
operation,  with  which  the  child  lived.  I  saw  the  same  operation 
performed,  but  without  success,  at  the  Hospice  de  la  Maternite 
at  Angers,  by  M.  Ouvrard,  upon  an  infant  in  whom  the  rectum 
was  deficient,  and  where  the  colon  terminated  in  a  cul-de-sac  at 

*  Sabatier,  loc.  cit.  p.  42a  t  See  Appendix,  page  577. 


284  ON   THE    DISEASES   OF   INFANTS. 

the  upper  extremity  of  the  sacrum.*  Callisen  has  recommended 
that  an  incision  be  made  in  the  lumbar  region  between  the  pos- 
terior border  and  the  crest  of  the  os  ilium,  parallel  to  the  posterior 
border  of  quadratus  muscle,  in  order  to  reach  the  colon  in  a 
point  where  it  is  in  a  measure  outside  of  the  peritoneal  cavity. 
Whatever  advantage  there  may  apparently  be  in  this  method  of 
operating,  Sabatier  gives  the  preference  to  that  of  Littre. 

Congestions  of  the  intestinal  tube. — We  have  seen  that,  in  a 
state  of  health,  the  intestinal  tube  of  young  infants  is  generally 
injected ;  that  it  almost  always  exhibits  a  rosy  appearance,  and 
that  the  digestive  tube  very  often  presents  a  number  of  vascular 
ramifications  throughout  its  length.  This  evidently  arises  from 
the  facility  with  which  a  reflux  of  blood  takes  place  in  the  large 
intestinal  vessels,  and  particularly  in  the  venous  system  when  any 
obstacle  whatever  is  opposed  to  a  free  circulation  of  blood  in  the 
various  branches  of  the  vessels.  This  injection,  which  is  so  fre- 
quent and  almost  normal  in  the  intestinal  vessels  of  young  in- 
fants, exhibits  a  great  analogy  to  that  which  is  seen  in  old  men. 
In  the  latter,  the  circulatory  apparatus  has  lost  its  vital  activity, 
and  the  regularity  of  its  functions,  in  consequence  of  the  modifica- 
tions or  organic  alterations  in  the  principal  agents  of  circulation. 
In  young  infants  it  has  not  as  yet  acquired  this  regularity,  from  an 
opposite  cause,  which  is,  that  the  organic  modifications  necessary 
to  the  accomplishment  of  the  functions  of  the  heart  and  lungs, 
have  not  yet  begun,  but  which  will  take  place  in  the  course  of 
time.  But  whatever  be  the  difference  of  the  cause,  the  effects 
are  the  same ;  and  here,  as  in  many  other  instances,  we  are  able 
to  make  one  of  those  approximations  to  the  truth,  which,  hold- 
ing united  causes  and  effects,  together  constitute  the  assem- 
blage of  the  phenomena  of  life,  unveil  to  us  their  nature,  and  aid  us 
in  foreseeing  their  consequences.  Let  us  see  to  what  point  these 
congenital  congestions  may  exist,  without  injury  to  the  digestive 
functions,  and  without  requiring  from  us  the  assistance  of 
our  art. 

The  passive  congestion  of  the  digestive  tube  may  appear 
in  three  different  manners — ramified  injection — capillary  injec- 
tion— and  a  redness  spread  over  several  parts  of  the  digestive 

*  This  case  will  be  found  in  the  Precis  de  Vart  des  accouchmens  de  M.  Chevreuil, 
2d  edit.    Parig,  1836. 


ON   THE    DISEASES    OP    INFANTS.  285 

tube,  with  or  without  sanguineous  exhalation  on  its  surface. 
The  passive  nature  of  these  different  degrees  of  injection  may  be 
recognised  by  the  superabundance  of  venous  blood  in  the  abdo 
minal  veins,  in  the  liver,  and  in  the  heart  and  lungs  ;  this  fluid 
has  regurgitated  in  the  intestinal  veins,  to  their  smallest  ramifi- 
cations.* This  condition  is  very  common  in  young  infants,  and 
particularly  in  those  who,  after  a  tedious  birth,  are  in  a  state  of 
asphyxia. 

The  ramified  injection  which  exists  in  the  intestinal  tube  of 
almost  all  new-born  children,  does  not  produce  any  functional 
disorder,  but  it  is  necessary  to  open  the  body  to  ascertain  its  ex- 
istence ;  it  is  even  possible  that  it  may  not  occur  until  the  mo- 
ment of  the  death  of  the  child,  and  that  it  may  be  the  result  of 
the  slowness  of  the  flow  of  blood  at  that  time.  As  to  the  capil- 
lary injection  and  the  local  or  general  redness  which  is  met  with 
in  different  parts  of  the  digestive  tube  in  young  infants,  or  in 
those  a  little  advanced  in  age,  they  are  the  result  of  passive  con- 
gestions which  often  give  rise  to  a  series  of  symptoms  which  the 
analysis  of  some  facts  enables  us  to  appreciate. 

I  have  examined  with  much  care,  twenty-five  cases  of  passive 
congestion  of  the  intestinal  tube,  without  hemorrhage,  in  children 
who  have  died  a  few  hours  or  a  few  days  after  their  birth ;  fif- 
teen of  them  exhibited  all  the  characters  of  a  state  of  apoplexy. 
The  symptoms  relating  to  the  digestive  apparatus,  were  nothing ; 
those  only  were  observed  which  related  to  the  state  of  congestion 
of  the  lungs  and  heart ;  and  the  intestinal  congestion,  which  was 
an  effect  of  that  of  the  respiratory  apparatus,  was  not  ascertained 
until  the  opening  of  the  body. 

Although  this  remark  may  appear  to  be  of  a  negative  charac- 
ter, still  it  is  worthy  of  attention,  for  we  ought  to  conclude  from  it, 
that  whenever  a  child  is  born  apoplectic,  the  digestive  apparatus 
will  also  partake  of  the  congestion  of  the  circulatory  organs,  and 
both  ought  to  be  the  objects  of  our  attention. 

If  the  passive  congestion  of  the  digestive  tube  does  not  give 
rise,  during  the  first  periods  of  life,  to  very  severe  symptoms,  on 
account,  doubtless,  of  the  incomplete  establishment  of  the  func- 

*  For  details  upon  the  different  aspect  of  passive  redness,  and  that  arising  from  inflam- 
mation, consult  my  work  "(Swr  la  membrane  muqueuse  gastro-intestinal"  p.  146. 


286  ON  THE  DISEASES  OP  INFANTS. 

tions  of  this  apparatus,  it  is  not  the  case  afterwards  ;  for  this  pas- 
sive congestion  may  become  the  direct  cause  of  several  conse- 
cutive consequences,  which  it  is  necessary  to  point  out. 

Intestinal  hemorrhage. — Rather  a  frequent  consequence  of 
this  general  injection  of  the  intestines,  is  intestinal  hemorrhage, 
which,  in  the  case  Vv^e  are  now  considering,  really  deserves  the 
name  of  passive  hemorrhage.  The  analytical  examination  of 
some  facts  will,  doubtless,  contribute  to  elucidate  this  point  of 
pathology. 

I  have  examined  fifteen  cases  of  passive  intestinal  hemorrhage ; 
there  were  eight  children  aged  from  one  to  six  days,  four  from 
six  to  eight,  and  three  from  ten  to  eighteen  days.  Six  of  these 
were  males,  and  nine  females.  Most  of  them  were  remarkable 
for  the  plethoric  condition  of  their  bodies  and  the  general  con 
gestion  of  their  integuments.  Some,  on  the  contrary,  were  pale 
and  feeble,  as  is  common  after  abundant  hemorrhage.  In  all, 
the  large  abdominal  vessels,  the  liver,  spleen,  lungs,  and  heart, 
were  considerably  engorged  with  blood ;  in  nine,  the  foetal  open- 
ings were  obliterated,  or  were  nearly  so ;  in  the  remainder,  they 
were  still  open.  In  all,  there  was  a  considerable  injection  of  the 
meninges  in  the  brain  and  spinal  marrow ;  and  in  all,  the  intes 
ti'iial  tube  contained  blood  more  or  less  red  and  more  or  less 
blackish,  exuded  and  spread  out  in  some  of  the  convolutions,  or 
accumulated  in  clots  in  various  parts  of  the  digestive  tube.  The 
detailed  history  of  one  or  two  of  these  cases  will  furnish  us  with 
the  principal  characters  which  distinguish  the  disease  in  general. 

CASE  XLI. — Muguct,  intestinal  hemorrhage. — Bathilde  Fan- 
tase,  a  girl  aged  eleven  days,  entered  the  infirmary  on  the  30th  of 
June.  She  possessed  a  medium  strength,  and  the  integuments  were 
of  a  healthy  color ;  but  she  was  affected  with  a  copious  diarrhoea  of 
green  discharges  ;  she  also  vomited  her  drinks.  Her  face  occasion- 
ally became  more  pale ;  the  pulse  was  frequent  and  hard,  beating 
from  ninety-two  to  ninety-five  pulsations  ;  some  points  of  muguet 
appeared  on  the  edges  of  the  tongue.  (Gvmmed  barley-water^  sin- 
apised  pediluvium,  demulcent  electuary.)  On  the  3d  of  July,  the 
same  symptoms  continued,  but  the  respiration  had  become  more  dif- 
ficult; the  pulse  was  less  frequent,  but  irregular  ;  the  pulsations  of 
the  heart  were  very  strong  ;  the  cry  was  sometimes  smothered.     On 


ON   THE    DISEASES    OP    INFANTS.  287 

the  fourth,  a  discharge  of  blood  took  place  from  the  anus,  the  cir- 
cumference of  which  was  red  and  tumefied  ;  there  was  a  slight  ten- 
sion of  the  abdomen  ;  rigidity  and  coldness  of  the  limbs,  and  the  res- 
piratory movements  were  very  painful.  The  face  became  pale,  the 
cry  feeble  and  smothered,  and  could  scarcely  be  heard  ;  pulse  small 
and  very  slow  ;  a  universal  sinking  took  place.  (Sweetened  water, 
dry  frictions,  milk  and  water.)  Death  occurred  on  the  fifth.  On 
examining  the  body,  a  shght  layer  of  muguet  was  found  on  the 
tongue,  and  a  well-marked  injection  of  the  cesophagus,  together  with 
a  general  capillary  injection  of  the  intestinal  tube ;  the  small  intes- 
tines were  covered  throughout  their  whole  length  with  a  layer  of 
blood  of  a  bright  vermilion  color,  about  the  commencement  of  the 
ileon,  but  of  a  much  deeper  color,  resembling  lees  of  wine,  towards 
the  ileo-caecal  region.  The  caecum  and  colon,  which  were  much  in- 
jected, contained  a  large  quantity  of  black  coagulated  blood.  When 
a  portion  of  the  intestine,  which  was  tinged  with  the  blood,  was  ma- 
cerated for  a  day  in  water,  it  lost,  by  degrees,  its  red  color,  and  the 
injection  in  the  vessels  almost  wholly  disappeared.  The  venae  cavae 
were  filled  with  black  fluid  blood.  The  lungs  engorged  at  their  pos- 
terior border,  were  still  crepitant  at  the  anterior ;  the  heart  was  filled 
with  blood  ;  the  ductus  arteriosus  partially,  and  the  foramen  ovale  en- 
tirely closed  ;  the  brain  was  very  soft  and  much  injected. 

This  child,  doubtless,  died  from  intestinal  hemorrhage,  which, 
insensibly  becoming  more  abundant,  was  necessarily  fatal. 

When  the  hemorrhage  is  prolonged,  if  the  blood,  instead  of 
being  discharged,  remains  in  the  intestinal  tube,  it  assumes  a 
brown  or  black  color,  and  the  alvine  evacuations  exhibit  a  great 
resemblance  to  black  vomitings  with  which  new-born  children 
are  sometimes  affected,  and  of  which  we  have  already  spoken. 

CASE  XLII. — Marie  Forbier,  aged  eighteen  days,  entered  the  in- 
firmary on  the  9th  of  March.  She  was  small  and  thin  ;  the  abdomen 
was  tender  to  the  touch ;  and  she  was  affected  with  the  commencement 
of  marasmus  ;  tongue  red  at  its  edges  ;  alvine  evacuations  green. 
(Cataplasm  to  the  abdomen,  milk  and  water.)  From  the  nmth  to 
the  thirteenth,  there  appeared  to  be  some  melioration  of  the  symp- 
toms. On  the  thirteenth,  the  muguet,  which  had  disappeared,  again 
showed  itself  with  increased  intensity,  and  was  spread  over  almost 
the   whole  of  the  tongue.     On  the  eighteenth,  the  child  passed  by 


288  ON   THE    DISEASES    OF    INFANTS. 

stool  a  large  quantity  of  black  matters.  She  became  extremely  fee- 
ble ;  pulse  slow  and  small ;  the  cry  could  scarcely  be  heard.  She 
died  on  the  nineteenth. 

Post  mortem  examination. — General  paleness  of  the  body ;  a 
layer  of  muguet  upon  the  tongue  ;  brown  viscid  matters  in  the  sto- 
mach, where  a  large  number  of  uninflamed  mucous  follicles  were 
found ;  a  general  discoloration  of  the  mucous  membrane  of  the 
small  intestines,  to  the  surface  of  which,  mucus  streaked  with  blood, 
was  found  adhering,  and  a  large  quantity  of  brown  matters  resem- 
bUng  that  which  the  child  had  discharged.  The  large  intestines  were 
in  the  same  state.  The  liver  was  a  little  injected  ;  the  large  abdomi- 
nal vessels  were  distended  with  a  quantity  of  black  liquid  blood  ;  the 
lungs  flabby,  and  but  slightly  crepitant ;  the  heart  was  empty  and  re- 
markably relaxed  ;  the  foetal  openings  were  obliterated,  and  the  brain 
was  in  a  healthy  state. 

I  will  not  multiply  the  instances  of  this  passive  hemorrhage  of 
the  digestive  tube,  to  which  a  great  number  of  infants  succumb ; 
the  other  cases  in  my  possession  strikingly  resemble  those  which 
I  have  already  reported. 

The  first  object  we  should  have  in  view  in  the  treatment  of 
passive  hemorrhage,  is  to  relieve,  at  the  same  time,  the  conges- 
tion of  the  circulatory  apparatus,  and  that  of  the  intestinal  tube* 
this  is  to  be  done  by  the  application  of  one  or  two  leeches  to  the 
anus.  It  would  be  advisable,  also,  to  give  the  child  cold  drinks 
slightly  acidulated,  with  the  syrup  of  quinces,  or  some  drops  of 
nitric  acid,  or  water  of  Rabel.  It  cannot  be  too  strongly  recom- 
mended to  accoucheurs,  to  allow  the  umbilical  cord  to  bleed 
when  a  child  is  observed  to  be  in  a  state  of  asphyxia  ;  for  it  has 
already  been  seen  what  serious  effects  follow  from  a  superabun- 
dance of  blood  in  young  infants.  Intestinal  congestions  and  he- 
morrhages are  not  only  serious  in  themselves,  but  they  are  also 
dangerous  from  the  existing  condition  of  the  circulating  organs, 
the  important  functions  of  which  are  impeded  or  suspended. 

DISEASES  OF  THE  INTESTINAL  TUBE  DEVELOPED  AFTERBIRTH. 

We  have  established  a  difference  between  the  diseases  of  the 
stomach  which  consist  in  a  disturbance  of  its  functions  without 
inflammation,  and  those  in  which  there  is  inflammation  with  or 
without  disturbance  of  function.     The  same  observation  is  appli- 


ON    THE    DISEASES    OF    INFANTS.  289 

cable  to  the  diseases  of  the  intestinal  canal,  and  we  will  begin  by 
studying  the  causes  and  nature  of  diarrhoBa  without  enteritis,  as 
we  considered  vomiting  and  gastric  indigestion  without  gastritis* 

Art.  1. — Intestinal  Indigestion. 

There  are  a  great  number  of  sucking  children  affected  with 
diarrhoea  without  enteritis ;  they  become  pale  and  sink  into  a 
state  of  marasmus,  and  upon  examining  the  dead  body  no  trace 
of  inflammation  will  be  found  in  the  intestines.  These  children 
really  perish  from  want  of  food  ;  they  die,  it  may  be  said,  of  hun- 
ger^the  instestinal  canal  not  digesting  either  the  milk  that  is 
sucked,  or  that  which  is .  given  to  drink.  Let  us,  in  the  first 
place,  examine  what  are  the  external  signs  of  this  intestinal  in- 
digestion, and  afterwards  seek  for  its  cause. 

These  signs  are — progressive  emaciation)  paleness  of  the  face^ 
continual  huno^er  of  the  child,  who  seizes  the  breast  with  extra- 
ordinary  eagerness.  The  diarrhoea,  which  consists  of  white  mu- 
cous matters,  is'sometimes  so  fluid  as  to  soak  into  the  clothes  and 
stain  them,  like  the  fluid  which  flows  from  the  vagina  in  leucor- 
rhoea.  With  these  mucous  matters  there  are  often  mixed  lumps 
of  coagulated  milk,  which  has  passed  unaltered  through  the  in- 
testinal canal.  After  a  certain  time,  the  child  perishes  in  the 
last  stage  of  marasmus,  and  if  the  intestinal  tube  is  opened,  the 
mucous  membrane  is  found  without  color  through  its  whole  ex- 
tent, and  is  often  softened  ;  but,  in  this  case,  it  has  undergone  an 
alteration  of  tissue,  the  nature  of  which  will  be  examined  in  an- 
other place.  Sometimes  the  digestive  tube  is  inflamed,  ulcer- 
ated, and  disorganized,  to  a  greater  or  less  extent ;  but  the 
white  softening  is  the  lesion  most  frequently  met  with  in 
children  that  have  died  from  the  disease  now  under  considera- 
tion. In  the  year  1826,  I  examined,  after  death,  fifteen  cases  of 
chronic  diarrhoea  without  inflammation,  in  children  from  the 
age  of  fifteen  days  to  two  months.  In  eight  of  them,  I  discover- 
ed no  lesion ;  there  existed  nothing  but  a  general  discoloration 
of  the  integuments  and  of  the  intestinal  tube,  while  all  the  organs 
were  exsanguined.  During  life,  these  children  experienced  an 
incessant  vomiting  and  diarrhoea  ;  in  almost  every  one,  the  ab- 
domen appeared  to  be  distended  with  gas,  which  was  found  in 

37 


290  ON   THE    DISEASES    OF    INFANTS. 

great  abundance,  together  with  white,  frothy  fluid  matters,  upon 
examining  the  intestinal  tube.  In  two  others,  the  colon  con- 
tained some  green  floculi,  analogous  to  the  meconium  in  color 
and  consistence.  In  five  others,  there  were  different  lesions  of 
the  lungs  or  of  the  brain,  and  the  intestinal  tube  exhibited  the 
characters  which  I  have  just  described. 

This  discoloration  of  the  mucous  membrane  is  almost  always 
the  first  degree  of  a  species  of  softening,  which  must  not  be 
confounded  with  inflammation.  I  will  also  remark  that  the  in- 
testinal tube,  in  place  of  being  without  color  through  its  whole 
extent,  sometimes  exhibits  at  various  parts  red  patches  or  streaks, 
which  are  the  last  traces  of  a  normal  coloring,  or  of  the  conges- 
tion so  frequent  in  this  part  in  a  young  infant.  I  shall  return 
to  the  consideration  of  this  subject  when  speaking  of  the  soften- 
ing of  this  membrane.  This  alteration  of  the  tissue  is,  I  believe, 
one  of  the  effects  of  a  defective  nutrition,  for  the  consequences 
which  result  from  this  aberration  of  the  digestive  functions,  are 
not  confined  to  a  simple  marasmus,  such  as  have  been  described, 
but  other  lesions  happen,  and  which  will  be  examined  in  another 
place.  I  will  content  myself,  for  the  present,  with  referring  to 
those  cases  where  the  functions  of  the  intestinal  tube  are  per- 
verted without  any  appreciable  lesion  of  an  inflammatory  nature. 

Every  thing  connected  with  this  subject  leads  to  the  belief, 
that  this  defect  of  nutrition  consists  in  the  nature  of  the  food,  or, 
perhaps,  in  the  mode  of  suckling  to  which  the  infant  is  sub- 
jected. In  truth,  all  the  children  at  the  Hospice  des  Enfans 
Trouves,  and  who  are  confided  to  the  care  of  the  wet-nurses,  are 
pale,  thin,  and  in  a  bad  condition.  A  great  number  perish  in 
this  hospital  from  imperfect  nutrition ;  in  almost  all,  the  symp- 
toms which  they  present,  even  to  the  time  of  their  death,  arise 
from  an  evident  disturbance  of  the  digestive  functions,  whether 
the  organs  discharging  this  function  are  inflamed,  or  whether 
they  have  arrived  at  the  stage  of  debility,  discoloration,  and  wast- 
ing, of  which  I  have  spoken.  In  all  probability  this  wasting 
arises  from  the  suckling  of  the  children  by  women  who  have  for 
a  long  time  discharged  the  office  of  nurse,  and  who  by  changing 
the  child  frequently,  feel  a  perfect  indifference  for  the  one  placed 
under  their  care,  and  establish  no  regular  hours  for  suckling, 
nor  fix  upon  the  quantity  of  milk  necessary  for  the  child ;  so 


ON    THE    DISEASES    OF    INFANTS.  291 

that,  always  hungry  from  receiving  but  little  substantial  nourish- 
ment, it  takes  too  large  a  quantity  at  a  time  of  a  liquid  which,  from 
its  superabundance  and  bad  quahty,  is  rendered  doubly  hurtful. 
This  is  the  proper  occasion  to  speak  of  the  interesting  re- 
searches of  M.  Payen,  the  distinguished  chymist,  who  has  made 
several  experiments  upon  the  nourishment  of  young  infants.* 

M.  Payen  observes,  that  during  the  period  of  suckling,  great 
disturbances  in  the  digestive  organs  frequently  either  proceed, 
accompany,  or  follow  a  forced  alteration  in  the  alimentation ;  and 
also  the  milk  that  appears  suitable  for  one  child  may  be  highly 
deleterious  to  another  of  the  same  age.  There  has  been  no 
more  success  in  substituting  the  milk  of  the  goat  for  that  of  a 
female.  This  is  what  M.  Payen  has  demonstrated  in  comparing 
the  physical  characters  of  several  kinds  of  milk  which  had  pro- 
duced different  effects  on  the  same  infant,  or  the  same  effects  on 
different  individuals. 

[Exjjerhnent  No.  1.)  The  milk  of  a  goat,  which  was  permit- 
ted to  run  at  liberty  in  the  fields  during  the  day,  and  which  was 
fed  at  the  stable  with  dry  food,  was  found  white,  opake,  without 
any  defined  odor,  and  of  a  density  equal  to  3  degrees  75  centiemes 
(Baume,)  having  no  sensible  action  on  the  tincture  of  turnsole. 
Fifty  grammes  of  this  milk,  treated  by  a  chymical  process  which 
is  too  long  to  be  reported  here,  gave  the  following  results : — 
Water,  with  some  traces  of  acetic  acid,  .  42.75 
Fatty  matter,  (butter,)        ....  2.04 

Caseum,  and  traces  of  insoluble  salts,  .  2.26 

Sugar,  soluble  salts,  and  some  traces  of  azotic 

matter,         .....  2.93 


Total,        49.98 
This  is  about  equal  to  14.5  of  solid  matter  for  every  100  parts 
of  milk. 

[Experiment  No.  2.)  The  milk  of  a  female  seven  months 
after  her  confinement,  in  a  healthy  condition  and  of  a  good  con- 
stitution, suckling  but  from  one  breast.  She  had  submitted,  as 
did  also  the  others  which  are  mentioned  below,  to  the  regimen 
most  suitable  for  nurses,  as  advised  by  physicians. 

*  Journal  de  Chimie  Medicale.  de  Pharmacie  et  de  Toxicologic,  recorded  by  the 
members  of  the  Societe  de  Chimie  Medicale,  March,  1828,  p.  118. 


292  ON   THE    DISEASES   OP    INFANTS. 

Physical  j)roperties. — White,  opaque,  of  the  density  repre- 
sented by  3°  5  of  Baume's  aerometer,  very  sensibly  alkaline  upon 
the  application  of  the  proper  test ;  which  alkaline  quality  con- 
tinued daring  the  entire  evaporation. 

Chymical  properties, — Fifty  grammes  of  this  milk  gave  the 
following  results : — 

Water,  ,  .  .  .  43.00 

Fatty  matter,  .  .  .  .  2.58 

Caseum,  and  traces  of  insoluble  salts,        .  0.09 

Sugar,  soluble  salts,  and  traces  of  azotic 

matter,  .  .  .  .  •  3.81 


Total,        49.48 

Equivalent  to  about  13  parts  of  solid  matter  to  every  100  of  milk. 

[Experiment  No.  3.)      Milk   of  a  healthy  female  eighteen 
months  after  her  confinement. 

Physical  properties. — Opake,  white,  alkaline,  indicating  3^  6 
of  Baume's  a3rometer. 

Chymical  properties. — Fifty  grammes  were  composed  of —  . 
Water,  .  .  -  .  42.80 

Fatty  matter,         .  .  .  .  2.60 

Caseum,  etc.  .  -  -  _  0.125 

Sugar,  soluble  salts,  etc.    -  -  .    .  3.965 


Total,        49.490 

About  13.4  solid  matter  for  every  100  of  milk. 

[Experiment  No.  4.)  Milk  of  a  female  in  good  health,  of  a 
larger  size  and  more  corpulent  than  the  preceding,  four  months 
after  her  confinement.  This  milk  indicated  3°  55  of  Baume's 
aerometer,  and  yielded  the  same  as  the  others,  in  the  following 
proportions,  in  the  fifty  grammes  submitted  to  the  experiment : — 

Water,  .            .            .            .  42.90 

Fatty  matter,  -            .            -            .  2.59 

Caseum,  etc.  -            -            •            -  0.12 

Sugar,  salt,  etc.  ....  8.93 

Total,        54.54 
About  13.8  solid  matter  in  100  parts  of  milk. 


ON   THE  DISEASES   OF    INFANTS.  293 

Several  other  specimens  of  milk,  taken  from  females  from  four 
to  twenty  months  after  confinement,  gave  the  like  results  as  those 
in  experiments  Nos.  3,  4,  and  5. 

Fro.n  this  it  appears  that  the  milk  of  the  female  differs  from 
that  of  the  goat  principally  in  its  marked  alkaline  quality,  and  in 
its  containing  about  half  the  quantity  of  caseum. 

As  to  the  milk  of  the  females,  under  the  circumstances  just 
mentioned,  it  difiers  in  respect  to  its  composition.  That  in  ex- 
periment No.  2,  contained  one  third  less  of  caseum,  and  I  also 
observed  that  this  milk  always  issued  in  a  much  larger  quantity 
from  the  breast.  The  children  under  the  care  of  each  of  those 
females  were  in  good  condition. 

These  data  are  certainly  of  the  greatest  interest,  and  they  be- 
come still  more  important,  when  we  apply  them  to  the  regimen 
of  suckinof  infants.  Let  us  therefore  examine  still  further  the 
dissertation  of  M.  Payen,  and  quote  his  remarks  at  length  at  the 
end  of  his  paper. 

"  A  child  aged  seven  months  and  a  half,  healthy  at  the  time  of 
birth,  although  it  had  evidently  suffered  a  little  from  too  slender 
nourishment  during  the  first  months,  in  consequence  of  the  acci- 
dental diminution  of  the  milk  of  several  nurses  in  whose  charge 
it  had  been  successively  placed,  was  fed  for  ten  days  with  the 
spoon,  with  thin  oatmeal  water  mixed  with  a  tenth  part  of  goat's 
milk,  taken  four  times  during  the  day  and  twice  at  night,  rather- 
less  than  a  quart  in  twenty-four  hours  containing — 

Solid  substances  of  milk,  .  .  14  grammes 

Dry  extract  of  the  oatmeal,      .  .  16 

Total,  30 

During  this  time  the  infant  thrived,  but  a  nurse  better  than  the 
former  was  sought  for  ;  and  one  was  at  last  chosen  who  appeared 
to  have  abundance  of  milk,  and  possessed  a  healthy  look.  This 
was  the  female  whose  milk  was  made  the  subject  of  the  experi- 
ment No.  2.  The  child  sucked  greedily,  and  the  milk  flowed 
abundantly ;  but,  from  the  third  time  of  nursing,  the  stomach 
was  overloaded,  the  mouth  remained  open,  and  the  child  ceased 
to  smile  in  its  usual  manner.  During  the  night  the  sleep  was 
much  disturbed.  The  physician  then  advised  that  the  child 
should  be  kept  at  the  breast  but  three  minutes  at  a  time. 


294  ON   THE    DISEASES   OF    INFANTS. 

"  The  untoward  symptoms  returned  with  increasing  intensity, 
repeated  vomitings  took  place,  and  one  of  them  was  followed  by 
syncope. 

"  I  determined  to  make  an  experiment  with  this  milk  ;  and  in 
the  first  place  I  measured  the  quantity  taken  by  the  child  in  five 
or  six  times  in  twenty-four  hours.  I  ascertained  it  to  be  more 
than  eleven  decilitres.  Having  also  discovered  the  proportion  of 
the  solid  matter  it  contained,  I  found  that  this  measure  repre- 
sented 160  grammes,  that  is  to  say,  five  times  more  than  the  milk 
of  the  goat  diluted  with  oatmeal  water.  In  addition  to  this,  the 
flow  of  milk  was  so  easy,  that  the  child  sucked  this  quantity  in 
less  than  ten  minutes. 

"  I  informed  the  physician  of  these  facts,  and  of  the  quantity 
of  butter  which  I  found  in  the  milk  of  this  female  ;  he  immedi- 
ately decided  to  stop  the  suckling,  and  to  substitute  milk  and 
water ;  the  unfavorable  symptoms  disappeared  in  a  few  days, 
sleep  and  liveliness  returned,  while  the  strength  of  the  nourish- 
ment was  gradually  increased  to  a  third  of  the  proportion  of 
milk." 

I  have  reported  this  fact  in  detail,  because  it  suggests  to  us  the 
precautions  necessary  to  be  taken  in  managing  the  suckling  of 
children.  When  a  child  appears  feeble  and  pale,  and  does  not 
digest  the  milk  of  its  nurse,  it  is  well  to  attempt  the  feeding  it 
with  the  spoon  or  bottle,  to  regulate  the  quantity,  and  to  correct 
the  quality,  by  diluting  it  with  barley-water.  I  have  often  seen 
at  the  Hospice  des  Enfans  Trouves,  goats'  milk  diluted  with  bar- 
ley-water, perfectly  digested  by  those  children  who  rejected  the 
milk  of  their  nurses,  and  who  had  wasted  away  daily  from  de- 
fect of  alimentation. 

However  much  we  may  be  gratified  with  the  feeling,  so  elo- 
quently expressed  by  one  of  our  most  beautiful  writers,  that  is 
produced  in  contemplating  as  a  law  of  nature,  the  suckling  of 
the  infant  by  the  mother,  and  which  it  is  believed  to  be  a  duty 
implicitly  to  obey,  we  may  nevertheless  find  some  exceptions  ; 
and  where  the  mother  may  be  obliged  to  renounce  this  most  no- 
ble of  duties.  We  should  not  forget  that  our  social  state  often 
removes  us  far  from  the  state  of  nature,  and  that  there  exist  cir- 
cumstances where  it  would  be  absurd  to  force  a  mother  to  nurse 
a  feeble  infant,  for  the  sole  reason  that  it  is  the  order  of  nature 


ON   THE    DISEASES    OF    INFANTS.  295 

that  an  infant  should  only  live  on  the  milk  of  a  woman  during 
the  first  months  of  its  life.  I  repeat  it,  that  suckling  by  the 
mother  ought  not  to  be  considered  so  generally  and  exclusively 
necessary  as  to  be  deemed  the  only  means  suitable  for  nourishing 
feeble  infants.  Every  mode  of  alimentation  should  be  tried,  and 
that  adopted  which  is  found  best  for  the  digestive  apparatus  of 
each  infant.  I  would  again  recommend,  in  such  cases,  to  use 
the  different  varieties  of  food  which  have  been  already  men- 
tioned, when  treating  of  gastric  indigestion. 

Art.  2. — Invagination  of  the  Intestines. 

Intestinal  invagination  is  of  very  frequent  occurrence  in  suck- 
ing infants ;  it  may  not  show  itself  by  any  symptom,  for  I  have 
often  found  it,  on  a  post  mortem  examination,  in  children  who^ 
during  life,  were  affected  with  nothing  more  than  constipation, 
and  who  appeared  not  to  have  had  any  abdominal  pains ;  yet  it 
is  very  possible  that  obstinate  constipation,  considerable  tension  of 
the  abdomen,  excessive  pain,  and  even  death  itself  may  follow 
intestinal  invagination,  particularly  if  the  mucous  membrane  of 
the  invaginated  portion  become  inflamed ;  and  then  it  may  be 
considered  as  one  of  the  most  serious  affections  of  early  infancy. 
Obstinate  constipation,  progressive  tumefaction  of  the  abdomen, 
vomiting  of  drinks,  and  afterwards  of  intestinal  and  sterco- 
raceous  matters,  in  a  word,  the  symptoms  which  we  have  pointed 
out  when  treating  of  imperforation  of  the  rectum,  show  them- 
selves in  intestinal  invagination,  when  complicated  with  a  com- 
plete interruption  of  the  passage  of  the  contents  in  the  digestive 
tube.  This  condition  is  very  difficult  to  remedy ;  yet  we  should 
attempt  to  establish  the  functions  of  the  digestive  tube  by  the  use 
of  baths,  by  abstinence  from  the  breast,  laxative  enemeta,  gentle 
compression  of  the  abdomen,  and  lastly,  by  the  administration 
of  a  dessert  spoonful  of  olive  oil. 

A  complete  interruption  to  the  passage  of  intestinal  matters, 
together  with  its  consequences,  may  arise  from  other  causes  ;  the 
consideration  of  which  we  will  hereafter  make  the  subject  of  our 
inquiries. 

Is  the  intestinal  tube  of  young  infants  susceptible  of  becoming 
the  seat  of  nervous  colic,  such  as  ileus,  miserere,  etc.  ?     And  is 


296  ON   THE    DISEASES   OF   INFANTS. 

the  excessive  pain  in  the  bowels  of  young  infants,  which  is  in- 
creased on  pressure,  and  known  by  their  restlessness  and  obsti- 
nate cries,  always  simply  nervous,  and  not  the  effect  of  inflam- 
mation of  some  of  the  abdominal  organs  ?  I  do  not  think  so. 
I  believe  that  the  violent  colics  to  which  children  are  exposed, 
are  as  often  owing  to  well-marked  anatomical  lesions,  as  to  a  sim- 
ple morbid  exaltation  of  sensibility  ;  it  is  indeed  what  we  shall 
demonstrate  in  the  course  of  these  researches. 

Whichever  it  may  be,  if  a  physician  be  called  to  a  young  in- 
fant suffering  from  violent  abdominal  pains  ;  if  they  are  accom- 
panied with  constipation,  vomitings,  and  even  convulsions ;  if 
they  are  remarkable  for  their  alternate  remissions  and  exacerba- 
tions, and  have  not  been  preceded  or  accompanied  by  symptoms 
of  enteritis,  the  existence  of  a  nervous  affection  of  the  digestive 
tube  may  be  then  suspected,  and  antispasmodics,  such  as  a  little 
ether  diluted  with  water,  or  syrup  of  poppies  mixed  with  sweet- 
ened water,  may  be  administered.  But  we  should  use  these 
means  with  great  caution,  and  not  forget  that  nervous  affections 
of  the  digestive  tube  are  much  more  rare  than  inflammations  in 
young  infants. 

Art.  3. — Inflammations  of  the  Digestive  Tube. 

The  intestinal  mucous  membrane  may  become,  like  that  of  the 
stomach,  the  seat  of  different  varieties  of  inflammation.  We 
shall  then  consider  in  succession,  erythematic,  follicular,  and 
gangrenous  enteritis.  Enteritis  with  altered  secretion,  or  muguet 
of  the  intestines,  is  very  rare  ;  yet  it  may  occur,  and  we  shall 
give  one  example  of  it. 

We  will  commence  on  the  subject  of  inflammation  of  the  in- 
testines developed  before  birth,  arriving  afterwards  at  the  exami- 
nation of  enteritis  occurring  in  infants  after  this  period. 

§  I.  Intestinal  inflammation  during  intra-uterine 
LIFE. — The  state  of  congestion  of  the  intestines,  even  before  birth, 
necessarily  exposes  these  organs  to  inflame  during  intra-uterine 
life.  The  observers  of  this  condition  have  given  us  several  ex- 
amples, but  their  descriptions  are  sometimes  of  so  dubious  a 
nature,  that  we  can  scarcely  put  any  confidence  in  them;  yet  we 


ON   THE    DISEASES   OF    INFANTS,  297 

may  refer  to  a  very  curious  case,  described  by  Professor  Desor- 
meaux,  in  his  article  Pathologie  de  Vmuf^  in  the  Dictionaire  de 
Medecine,  in  21  volumes.  I  had  charge  of  an  infant,  says  he, 
some  years  since,  born  of  a  mother  who  had  enjoyed  excellent 
health  during  her  pregnancy.  This  child,  when  born,  was  ex- 
tremely emaciated  ;  the  surface  of  the  body  was  of  a  yellowish 
white,  with  an  expression  of  face  like  that  of  an  old  person  suf- 
fering with  pain.  The  abdomen  of  this  little  patient  was  swelled, 
hard,  and  painful ;  the  convolutions  of  the  intestines  were  easily 
discovered  beneath  the  integuments  ;  all  the  symptoms  announced 
the  existence  of  enteritis  of  long  standing.  It  was  placed  under 
the  care  of  a  good  nurse,  and  notwithstanding  its  extreme  feeble- 
ness, it  was  able  at  first  to  receive  a  few  drops  of  milk,  and  after- 
wards to  suck,  and  subsequently  became  a  fine  and  healthy  child. 
As  the  anatomical  examination  of  this  case  did  not  occur  for 
its  more  complete  elucidation,  I  will  add  others  which  I  have 
seen,  and  where  the  post  mortem  examination  of  the  disease  re- 
moves all  doubts  as  to  its  nature. 

CASE  XLIII. — Enteritis,  excrescence  or  vegetation  on  the  sur- 
face  of  the  duodenum. — Blanchard,  a  boy,  was  brought  to  the  Hos- 
pice des  Enfans  Trouves  on  the  11th  of  December,  1826.  This 
child  was  pale,  thin,  and  very  small ;  he  remained  for  six  days  under 
the  care  of  the  wet-nurses,  but  instead  of  increasing  in  strength,  he 
became  rapidly  more  emaciated,  with  an  incessant  diarrhoea,  together 
with  vomiting.  He  entered  the  infirmary  on  the  seventeenth  ;  we  had 
hardly  an  opportunity  of  examining  the  case,  for  he  died  at  night. 
The  post  mortem  examination  was  made  on  the  succeeding  day.  I 
found  the  stomach  slightly  injected,  and  spotted  with  red  ;  some  red 
transverse  striae  existed  in  the  duodenum  ;  a  red,  irregularly  shaped 
excrescence,  resembling  a  strawberry,  was  found  about  the  middle 
of  the  second  portion  of  this  intestine.  It  was  about  the  size  of  a 
French  bean,  and  was  firmly  attached  by  a  pedicle  to  the  surface  of 
the  mucous  membrane  upon  which  it  was  developed  ;  it  resembled  in 
every  respect  the  excrescences  which  are  sometimes  formed  on  the 
surface  of  this  membrane  in  adults,  cases  of  which  I  have  reported. 
Its  structure  was  spongy,  but  not  erectile  ;  it  was  easily  crushed  be- 
tween the  fingers,  and  the  blood  which  it  contained  was  readily 
squeezed  out.  Besides  this  organic  alteration,  there  existed  at  the 
termination  of  the  ileon  a  chronic  inflammation,  characterized  by  a 

38 


298  ON   THE    DISEASES   OP    INFANTS, 

thickening  of  the  mucous  membrane,  which  was  of  a  strongly  mark- 
ed slate-color ;  striae  of  the  same  color  existed  in  the  colon.  There 
was  nothing  remarkable  in  any  of  the  other  organs. 

This  vegetation  of  the  duodenum  can  hardly  be  attributed  to 
chronic  inflammation,  and  it  is  very  difficult  to  explain  the  na- 
ture and  cause  of  these  kinds  of  excrescences,  which,  without 
doubt,  have  some  analogy  to  warts  on  the  skin.  But  the  slate- 
colored  appearance  of  the  ileon,  which  was  at  the  same  time 
tumefied,  must  be  regarded  as  an  incontestable  evidence  of  chronic 
inflammation ;  it  is  to  this  phlegmasia,  with  which  the  infant 
was  born,  that  the  languor,  rapid  emaciation,  and  death  must  be 
attributed. 

CASE  XLIV. — Chronic  colitis,  sclerosis  of  the  colon. — Joseph 
Camison,  aged  six  days,  entered  the  infirmary  on  the  22d  of  Septem- 
ber. He  exhibited  a  slight  icterous  tint,  was  affected  with  an  abun- 
dant diarrhoea,  and  was  in  a  very  advanced  state  of  marasmus. 
Since  his  birth,  emaciation  had  steadily  increased ;  the  face  very 
much  altered,  continually  expressed  the  presence  of  great  pain ;  a 
number  of  wrinkles  were  formed  on  the  forehead,  and  the  commis- 
sure of  the  lips  was  drawn  backward;  he  cried  but  little,  and  re- 
mained immoveable  in  his  cradle.  He  died  the  same  night  that  he 
entered  the  infirmary.  There  were  found,  on  a  post  mortem  exami- 
nation, a  passive  congestion  of  the  oesophagus,  and  a  spotted  redness 
of  the  stomach ;  the  duodenum  and  the  jejunum  presented  nothing 
more  than  a  slight  injection  ;  but  towards  the  extremity  of  the  ileon 
a  thickening  of  the  walls  of  the  intestines  commenced,  which  in- 
creased more  and  more  towards  the  cascum ;  the  ileo-cascal  opening 
was  much  contracted,  and  its  valve  more  red,  hard,  and  tumefied. 
This  thickening  was  more  particularly  in  the  sub-mucous  cellular 
layer ;  the  mucous  membrane  was  also  a  little  thickened,  very  red, 
and  quite  tender.  The  peritoneal  membrane  was  as  thin  as  in  the 
natural  state ;  so  that  the  cellular  membrane,  considered  by  itself, 
formed  a  membrane  of  half  a  line  in  thickness,  very  solid,  and  in 
color  resembling  pearl ;  its  tissue,  which  retained  no  longer  its  cel- 
lular form,  was,  on  the  contrary,  homogeneous,  and,  when  cut,  left  a 
smooth  surface.  This  lesion  presented  the  anatomical  characters 
assigned  by  Laennec  to  sclerosis.  It  existed  in  the  entire  lengtn  ot 
the  colon. 


ON  THE    DISEASES    OP    INFANTS.  299 

The  intestinal  matters  were  yellow,  liquid,  and  but  slightly  adhe- 
rent to  the  parietes  of  the  intestines. 

The  liver  was  black  and  gorged  with  blood  ;  the  bile  abundant, 
viscid,  and  of  a  deep  black.     The  lungs  and  brain  were  healthy. 

This  lesion  was  without  doubt  developed  during  the  intra- 
uterine life,  and  the  child  brought  with  it  the  chronic  colitis  of 
which  we  have  spoken ;  and  to  this  affection  must  be  referred 
the  state  of  feebleness,  diarrhoea,  and  the  rapid  emaciation  of  the 
patient  immediately  after  birth.  These  two  cases  of  congenital 
enteritis,  may  throw  some  light  on  the  state  of  feebleness  in 
which  some  infants  are  born,  and  where  life  is  scarcely  establish- 
ed, and  who  are  affected  with  lesions,  the  premature  develop- 
ment of  which  produce  an  important  change  in  the  young  em- 
bryo. This  should  also  prove  to  us  the  necessity  of  examining, 
with  the  greatest  attention,  the  nature  of  the  causes  to  which 
is  attributed  the  feebleness  of  birth. 

I  could  also  give  several  examples  of  con2:enital  lesions  of  the 
digestive  tube,  but  the  recital  of  their  history  would  occupy  too 
much  space  ;  I  will  simply  state  that  I  have  observed  ten  cases 
of  congenital  enteritis  in  infants  that  have  died  on  the  first  or 
second  day  after  birth.  In  three  of  them  there  was  an  evident 
inflammation  of  the  follicular  plexus  of  the  ileo-csecal  region. 
In  others,  there  existed  a  number  of  white  follicles,  slightly  pro- 
jecting, in  the  caecum,  surrounded  by  a  red  circle ;  ulceration 
had  commenced  on  the  summits  of  some  of  these  follicles.  In 
five  others,  the  inflammation  only  consisted  in  red  patches,  with 
tumefaction  and  friability  of  the  mucous  membrane  of  the  small 
intestines.  The  most  remarkable  thing  in  these  cases  was,  that 
the  meconium  exhibited  no  sensible  alteration,  but  possessed  its 
ordinary  consistence  and  aspect ;  the  children,  however,  were 
almost  all  pale  and  thin.  Yet  one  of  them,  where  the  follicular 
apparatus  was  inflamed,  was  strong  and  vigorous. 

The  symptoms  of  congenital  enteritis  are  analogous  to  those 
of  enteritis  which  is  developed  after  birth. 

§  II.  Inflammations  of  the  intestinal  tube  devel- 
oped AFTER  BIRTH. — Inflammation  of  the  mucous  membrane 
of  the  intestinal  tube  ought  particularly  to  be  noted  with  refer- 
ence to  the  varieties  of  its  seat ;  but  before  studying  it  in  this 


300  ON   THE    DISEASES    OF    INFANTS. 

respect,  let  us  examine  the  general  lesions  arising  from  the  phleg- 
masiae  of  the  interior  of  the  digestive  tube  of  young  infants. 

Inflammation  of  the  intestines  may  exhibit  the  same  anatomi- 
cal varieties  as  those  of  the  stomach ;  we  shall  therefore  make 
the  following  divisions  of  phlegmasia  of  the  bowels, 

ENTERITIS, 

Erythematic, 

With  altered  secretion ; 

Follicular, 

With  disorganization  of  tissue. 

Erythematic  enteritis. — There  is  a  very  trifling  differ- 
ence between  erythematic  inflammation  of  the  intestines  and 
the  passive  injection  of  which  they  are  often  the  seat  in  young 
infants,  and  it  is  very  diflicult  to  establish  the  line  of  demar- 
cation between  these  two  lesions.  We  can,  however,  say  that 
the  one  is  sometimes  the  predisposing  cause  of  the  other,  and 
that  if  the  intestinal  tube  is  so  frequently  inflamed  in  young 
infants,  it  is  because  it  is  almost  always  injected.  The  blood 
which  constitutes  this  passive  injection  becomes,  by  its  prolonged 
retention  in  the  vessels  or  in  the  tissue  of  the  membrane,  an 
irritating,  foreign  body,  which  may  produce  lesions  and  symp- 
toms peculiar  to  recent  inflammation. 

When,  in  place  of  a  simple  ramiform  capillary  injection,  the 
erythematic  inflammation  exhibits,  as  its  anatomical  characters, 
patches  of  redness  of  greater  or  less  extent,  indiflferently  situated 
either  in  a  dependent  or  other  part  of  the  digestive  tube,  accom- 
panied by  a  tumefaction  and  friability  of  the  mucous  membrane 
more  or  less  evident — the  lesion  is  then  evidently  inflammatory, 
and  is  often  the  result  of  a  true  passive  congestion.  To  obtain 
an  exact  knowledge  of  the  existence  of  erythematic  enteritis,  I 
have  particularly  remarked  the  symptoms  which  appeared  dur- 
ing the  life  of  those  children  that  showed  the  anatomical  lesions, 
the  characters  of  which  I  have  just  described.  The  following  is 
the  result  of  this  analytical  examination. 

I  have  seen  a  great  many  cases  of  erythematic  enteritis,  but 
many  of  them  were  accompanied  with  gastritis,  pneumonia,  etc., 


ON    THE    DISEASES    OF    INFANTS.  301 

and  if  they  were  accumulated  here  it  would  be  extremely  diffi- 
cult to  separate  and  group  the  symptoms  belonging  exclusively 
to  this  disease.  When  the  number  of  complicated  cases  was 
separated  from  those  which  existed  without  complication,  the  lat- 
ter is  reduced  to  forty.  They  were  of  different  ages,  from  one 
day  to  one  year.  In  thirty,  there  existed  a  diarrhcEa  of  yellow, 
liquid  matters  ;  in  six,  vomiting  of  drinks  ;  in  twenty-five,  dis- 
tention of  the  abdomen;  in  four,  natural  stools;  in  six,  there  was 
no  diarrhoea ;  in  five,  an  ery thematic  redness  about  the  anus, 
caused,  without  doubt,  by  t?ie  contact  of  intestinal  matters ;  in 
neither  of  them  was  there  abundant  transpiration  ;  in  almost  all, 
the  skiu  was  dry  and  burning ;  and  in  four  only  did  there  exist 
a  febrile  acceleration  of  pulse,  and  those  four  were  aged  from  five 
months  to  one  year.  In  twenty-five,  the  face  possessed  the  pe- 
culiar expression  of  pain,  characterized  particularly  by  vertical 
wrinkles  at  the  root  of  the  nose,  and  by  the  drawing  outward  of 
the  commissure  of  the  lips. 

Erythematic  enteritis  is  often  complicated  with  hemorrhage. 
In  four  of  these  children  where  there  existed  a  violent  inflamma- 
tion, blood  was  found  exhaled  in  different  parts  of  the  intestinal 
tube.  One  of  them  had  passed  a  considerable  quantity  both  by 
vomiting  and  stool.  We  have  already  seen  this  symptom  exist 
in  cases  of  passive  abdominal  congestion ;  but  the  hemorrhage 
now  under  consideration,  is  not  the  result  of  a  superabundance 
of  blood  in  the  intestinal  vessels  and  in  the  large  vascular  trunks 
of  the  abdomen,  but  is  evidently  a  sanguineous  exhalation  result- 
ing from  the  afflux  of  blood  by  the  stimulus  of  the  inflammation 
in  the  mucous  membrane.  The  following  is  an  interesting  case 
of  this  kind. 

CASE  XLV. — Marie  Colin,  aged  ten  days,  small,  but  of  good 
strength,  entered  the  infirmary  on  the  27th  of  September.  Her  cry  was 
well  sustained  and  complete  ;  integuments  were  of  a  vermilion  color. 
She  was  then  in  the  ninth  day  of  the  vaccine  disease,  which  had 
passed  regularly  through  its  stages.  She  cried  incessantly  ;  several 
points  of  muguet  appeared  on  the  borders  of  the  tongue,  the  mem- 
brane of  which  was  of  a  cherry  red ;  she  had  a  copious  diarrhoea,  but 
the  abdomen  was  not  tense.  {Gummed  rice-water,  emollient 
gargle,  starch  injections,  milk  and  water.)     On  the  twenty-eighth, 


302  ON    THE    DISEASES    OF    INFANTS. 

the  same  condition  ;  the  child  slept  none  ;  cried  night  and  day ;  was 
in  a  constant  state  of  restlessness  ;  the  face  continually  pinched,  ex- 
pressed pain  ;  diarrhoea  abundant,  and  mixed  with  a  considerable 
quantity  of  blood  ;  yet  she  did  not  become  much  emaciated.  The 
skin  was  hot  and  dry,  and  the  pulse  beat  about  sixty-six  in  a  minute. 
On  the  1st  of  October,  the  muguet  extended  to  the  internal  surface 
oif  the  lips  and  cheeks  ;  the  child  was  very  restless,  and  vomited  the 
drinks  for  the  first  time ;  there  were  several  streaks  of  blood  in  the 
matters  vomited.  (Sweetened  tilia,  warm  hath,  milk  and  water.) 
The  same  general  state  continued  for  several  days.  On  the  fourth, 
the  expression  of  the  face  was  much  altered  ;  the  abdomen  became 
distended,  and  when  compression  was  made,  wrinkles  vt^ere  observ- 
ed in  every  part  of  the  forehead  ;  the  muguet  formed  a  thick  layer 
on  every  part  of  the  tongue,  and  extended  to  the  lateral  part  of  the 
froenum  ;  the  cry  was  feeble  and  exhausted  ;  alvine  dejections  green, 
bloody,  and  very  abundant ;  abdomen  hard  and  tense  to  the  touch  ; 
thorax  resonant  in  all  parts.  Death  took  place  at  night,  and  the 
post  mortem  examination  was  made  the  next  day. 

The  body  still  retained  much  of  its  embonpoint ;  the  limbs  were  in- 
flexible ;  adipose  matter  was  thickened  in  different  parts  of  the  body  ; 
a  thick  layer  of  muguet  existed  above  and  below  the  tongue,  and  the 
inferior  extremity  of  the  oesophagus  was  the  seat  of  a  well-character- 
ized gelatinous  softening.  On  the  internal  surface  of  the  stomach 
there  was  only  found  a  spotted  redness  ;  there  existed  throughout 
the  whole  extent  of  the  digestive  tube  a  large  quantity  of  bloody 
matter  of  the  consistence  of  pitch.  In  different  parts  of  the  small  in- 
testines there  were  several  red  patches,  accompanied  with  a  well- 
marked  tumefaction,  and  a  great  friability  of  the  mucous  tissue, 
which  was  torn  with  the  nail  with  the  greatest  ease.  There  was 
found  besides,  some  blood  which  had  been  recently  effused  at  these 
inflamed  parts.  Several  follicular  patches,  red  and  tumefied,  were 
discovered  at  the  extremity  of  the  ileon.  The  ceecum  was  studded 
with  a  number  of  separate  follicles  slightly  inflamed,  and  there  existed 
in  the  colon  a  number  of  red  patches,  mixed  with  slate-colored  streaks. 

The  liver  was  not  much  more  colored  than  natural ;  the  gall  blad- 
der contained  liquid  bile  of  a  deep  green.  The  lungs  were  healthy ; 
the  right  lung  only  was  found  a  little  engorged  with  blood  at  its  base ; 
the  ductus  arteriosus  was  still  open,  and  the  foramen  ovale  closed. 
The  brain  was  firm,  and  much  injected. 

The  disease  of  which  this  child  died,  was  evidently  concen- 


ON   THE    DISEASES    OF    INFANTS.  303 

trated  in  the  intestinal  tube,  and  the  symptoms  produced  by  it 
are  remarkable  for  their  severe  and  positive  character  ;  a  copious 
green-colored  diarrhoea,  painful  expression  of  the  face,  continual- 
ly increasing  tension  of  the  abdomen,  ceaseless  motion,  caused, 
without  doubt,  by  pain,  and  in  the  midst  of  all  this  excitement, 
without  any  febrile  action,  are  the  symptoms  which  are  at  first 
presented  to  our  notice.  Soon  after,  vomiting  supervened,  and 
the  examination  of  the  body  leads  to  the  belief  that  this  was 
owing  to  a  softening  of  the  oesophagus,  which  took  place  to- 
wards  the  termination  of  the  disease.  Finally,  the  appearance 
of  blood  in  the  vomitings  and  injections,  are  sufficient  evidence 
of  the  existence  of  intestinal  hemorrhage.  The  traces  of  it  were 
found  upon  examining  the  body ;  and  in  analyzing  the  symptoms 
exhibited  by  this  child,  we  are  able  to  appreciate  their  value,  and 
can  thus  decide  on  the  existence  of  enteritis,  complicated  with 
hemorrhage. 

Erythematic  enteritis,  wherever  its  seat  may  be,  may  precede 
different  varieties  of  inflammation,  of  which  indeed  it  is  the  first 
stage,  and  assume  various  aspects  while  it  continues.  The  in- 
tense redness  which  is  peculiar  to  this  inflammation,  is  followed 
by  a  brown  or  slate  color,  diffused  in  patches,  striae,  or  points,  in 
various  parts  of  the  digestive  tube  ;  so  that  it  is  very  common  to 
find  in  infants  dying  after  a  prolonged  diarrhoea,  and  by  which 
they  are  reduced  to  a  state  of  complete  marasmus,  several  slate- 
colored  striae,  either  in  the  small  intestines  or  in  the  colon  ;  and 
this  alteration  of  color  in  the  mucous  membrane  ought  to  be  re- 
garded as  an  indication  of  chronic  phlegmasia. 

I  must  add,  that  enteritis  does  not  always  show  itself  in  a  man- 
ner so  strongly  marked  as  in  the  case  just  mentioned  ;  but  the  dis- 
ease may  be  recognised,  although  the  symptoms  be  not  quite  so 
clear,  by  comparison  with  those  in  the  case  which  I  have  chosen 
as  a  type. 

This  disease  is  often  complicated  with  gastritis.  Gastro-enter- 
itis  is  really  a  disease  of  common  occurrence  in  sucking  infants. 
The  symptoms  of  this  complication  do  not  differ  much  from 
those  belonging  to  simple  enteritis  ;  vomiting  of  greater  or  less 
obstinacy  exists,  but  it  is  very  common  to  see  children  vomit  who 
are  only  affected  with  enteritis  ;  the  presence  of  this  symptom, 
therefore,  will  not  enlighten  us  as  to  the  union  of  gastritis  with 


304  ON    THE    DISEASES    OF    INFANTS. 

enteritis.  One  of  the  most  probable  signs  of  the  existence  of 
these  two  diseases  simultaneously,  is  pain  in  the  epigastric  re- 
gion, indicated  by  a  painful  expression  of  the  face,  and  by  the 
cries  of  the  child  when  compression  is  made  on  this  region.  But 
may  not  this  be  a  very  vague  indication  ?  and  may  not  the  in- 
flamed colon,  which  is  near  the  place  of  pressure,  actually  be  the 
seat  of  the  pain  which  is  referred  to  the  stomach  ?  Thus,  then, 
if  pathological  anatomy  demonstrate  to  us  that  enteritis  is  often 
accompanied  by  gastritis,  clinical  observation  on  the  diseases  of 
young  infants,  is  not  sufficient  to  enable  us  to  distinguish  gastro- 
enteritis from  enteritis  alone.  What  1  have  observed  with  re- 
spect to  the  inflammation  now  under  consideration,  may  be  ap- 
plied to  other  phlegmasia.  In  all  cases,  however,  the  impossibi- 
lity of  making  this  distinction  is  of  little  consequence  in  a  thera- 
peutic point  of  view,  since  the  treatment  of  enteritis  is  perfectly 
applicable  to  gastro-enteritis. 

Enteritis,  with  altered  secretioti,  or  muguet  of  the  intestines. — 
The  alteration  of  the  secretion  which  constitutes  muguet,  may 
be  met  with  on  the  surface  of  the  mucous  membrane  of  the  in- 
testines during  its  inflammation.  I  have  met  with  one  instance 
of  this  altered  secretion  on  the  surface  of  the  ileon  :  but  as  I  did 
not  record  the  symptoms  which  appeared  during  the  life  of  the 
child,  I  will  not  report  the  anatomical  investigation.  I  will  here 
give  the  history  of  a  case  of  muguet  of  the  colon. 

CASE  XLVI. — Partial  softening  of  the  stomach,  muguet  of 
the  colon. — Louis  Simonet,  aged  three  days,  entered  the  infirmary 
on  the  21st  of  April,  for  a  severe  diarrhcea,  with  which  he  had  been 
affected  about  two  days.  He  exhibited  besides,  a  slight  icterous 
tint  over  the  whole  body.  (Sweetened  rice-water,  milk  and  water.) 
On  the  twenty-fifth,  the  icterous  disappeared,  and  the  child  vomited 
the  drinks  ;  the  diarrhoea  continued  abundant,  and  produced  a  rapid 
emaciation.  Death  occurred  on  the  twenty-seventh.  On  opening 
the  body,  the  buccal  membrane  was  found  healthy ;  there  was  a 
complete  disorganization  of  all  the  coats  of  the  stomach,  the  mucous 
membrane  of  which  exhibited  a  gelatinous  softening,  particularly 
about  the  great  tuberosity.  The  inferior  third  of  the  ileon,  the  cae- 
cum, and  the  colon,  were  red,  tumefied,  and  rough,  and  exhibited  on 
their  surfaces  a  great  number  of  flakes,  floating  in  the  midst  of  foRcal 


ON   THE    DISEASES    OP    INFANTS.  305 

matter,  of  the  consistence  of  cream,  liquid,  and  of  a  green  color;  but 
the  greatest  number  were  firmly  adherent  to  the  membrane,  and 
could  not  be  separated  without  scratching  them  with  the  scalpel* 
This  appearance  did  not  exist  in  the  sigmoid  flexure  of  the  colon  ; 
but  it  was  found  in  the  rectum,  in  which  were  several  deep  red, 
longitudinal  striae.  The  remainder  of  the  body  exhibited  nothing 
remarkable. 

It  is  impossible  not  to  admit  that  this  altered  secretion  bears  a 
resemblance  to  that  which,  in  the  mouth  and  stomach,  has  been 
called  muguet.  If  this  altered  secretion  be  analogous  to  the  false 
membranes  which  are  developed  on  the  surface  of  mucous  mem- 
branes generally,  we  must  not  be  surprised  to  see  it  developed  in 
the  colon,  since  inflammation  of  this  membrane  sometimes  pro- 
duces membranous  pellicles,  spread  to  a  greater  or  less  extent 
over  different  parts  of  its  surface,  as  is  seen  in  dysentery  and 
other  intestinal  phlegmasiag.  There  exists  no  symptom  peculiar 
to  muguet,  by  which  a  correct  diagnosis  can  be  made  of  it  in  the 
intestines.  The  case  reported  presented  nothing  more  than  the 
symptoms  of  enteritis,  and  it  has  been  recorded  as  an  instance  of 
the  variety  of  inflammation  which  we  have  designated  as  enteri- 
tis with  altered  secretion.  Perhaps  we  might  And  false  mem- 
branes in  the  colon  of  infants  ;  but  I  have  never  seen  them. 

Follicular  enteritis. — The  follicular  apparatus  of  the  intestinal 
tube  may  become,  like  that  of  the  stomach,  the  seat  of  various  al- 
terations. It  consists,  as  is  well  known,  of  small  isolated  glands 
in  the  upper  two  thirds  of  the  small  intestines,  grouped  in  oblong 
plexuses,  almost  always  occupying  the  free  borders  of  the  intes- 
tines, and  varying  greatly  in  number.  They  again  appear,  iso- 
lated, in  the  csecum  and  colon,  and  occur  even  in  the  rectum. 

In  their  natural  state  they  are  more  or  less  apparent ;  many 
children  do  not  show  them  at  all,  and  their  development  varies 
according  to  the  individual. 

The  changes  in  the  muciparous  follicles  of  the  intestinal  tube 
are  not  all  of  an  inflammatory  character.  They  experience,  for 
example,  at  the  period  of  dentition,  an  increase  of  vital  energy, 
which  augments  their  secretion  considerably,  and  renders  their 
size  larger,  and  their  number  greater,  but  which  still  does  not 
produce  any  redness,  tumefaction,  or  ulceration,  as  is  observed  in 

39 


306  ON   THE    DISEASES    OF    INFANTS. 

ordinary  inflammation.  It  is  important  for  us  to  stop  and  consi- 
der this  species  of  organic  and  functional  excitability  which  oc- 
curs in  the  follicular  apparatus  of  infants  at  the  breast. 

I  have  seen  isolated  follicles  and  follicular  plexuses  of  the  in- 
testinal tube,  in  considerable  numbers,  and  developed  without 
being  inflamed,  in  twelve  infants.  There  were  three,  aged  from 
eight  days  to  three  weeks ;  two  aged  two  months ;  the  remaining 
seven,  were  from  nine  months  to  one  year.  The  follicles  appeared 
at  the  commencement  of  dentition.  Ten  of  these  children  were 
aflected  with  diarrhoea  of  liquid,  v/hite  mucous  matters.  This  is 
really  the  serous  diarrhoea  of  authors  ;  and  every  symptom  leads 
to  the  belief  that  there  is  a  direct  relation  between  the  develop- 
ment of  these  follicles  and  the  augmentation  of  their  secretion. 
Most  of  these  children  had  arrived  at  the  period  of  dentition,  so 
that  there  appeared  a  remarkable  coincidence  between  the  period 
of  the  appearance  of  the  teeth  and  that  of  the  organic  develop- 
ment of  the  follicular  apparatus  of  the  intestines.  A  physiologi- 
cal explanation  may  be  given  of  this  coincidence.  In  fact,  the  fol- 
licular apparatus  appears  destined  to  second  the  action  of  the  in- 
testines in  digestion,  by  furnishing  the  surface  of  these  organs 
with  a  fluid,  which,  in  all  probability,  assists  in  the  elaboration 
of  aliments.  Dogs,  and  other  carnivorous  animals,  where  the  di- 
gestive power,  if  I  may  use  the  expression,  is  truly  remarkable, 
possess  this  apparatus  in  a  high  degree  of  development.  We 
ought  not  to  be  surprised  to  find  the  follicles,  or  the  muciparous 
plexuses,  augment  in  volume  and  activity  at  the  period  of  den- 
tition in  man,  since  the  organs  of  digestion  then  receive  a  modifi- 
cation which  renders  them  fit  to  fulfil  their  functions. 

It  appears  then,  that  nature  has  fixed  the  same  period  for  the 
development  of  all  parts  of  the  digestive  apparatus,  for  at  the  same 
time  the  salivary  glands  acquire  a  much  larger  size,  and  secrete 
saliva  in  greater  abundance. 

This  coincidence  in  the  normal  development  of  the  teeth,  and 
in  the  increase  of  size  and  activity  of  the  follicles,  explains  the 
relation  that  exists  between  dentition  and  the  frequency  of  the 
serous  discharges  from  the  bowels,  at  this  period,  in  infants ;  in 
this  manner,  then,  can  be  explained  the  sympathy  pointed  out 
by  authors  between  the  appearance  of  the  first  teeth  and  affec- 
tions of  the  bowels,  without  having  recourse  to  those  hypotheses 


ON    THE    DISEASES    OF    INFANTS.  307 

too  often  referred  to  in  researches  on  the  phenomena  of  life. 
There  is  here  a  remarkable  coincidence — or  if  the  expression  be 
thought  better,  a  morbid  functional  sympathy,  because  there  is 
a  coincidence  of  development. 

Although  children  do  not  exhibit  the  development  of  the  muci- 
parous follicles  before  dentition  so  often  as  after  this  period,  it 
must  not,  on  this  account,  be  thought  that  these  follicles  do  not 
exist  at  birth.  They  have  been  very  often  found  in  considera- 
ble numbers  from  the  first  moment  of  life  ;  but  generally  speak- 
ing, they  are  not  very  numerously  developed  in  the  intestinal  ca- 
nal, except  at  the  period  above  mentioned,  and  sometimes  even 
not  until  a  more  advanced  age. 

I  do  not  consider  this  morbid  development  of  the  muciparous 
follicles,  as  a  true  inflammation.  Nevertheless,  this  state  of  ex- 
citability which  causes  the  augmentation  of  their  secretion,  is,  as 
it  were,  an  intermediate  stage  between  the  normal  state  and  the 
state  of  inflammation  ;  and  it  would  be  proper  to  keep  the  child 
affected  with  this  diarrhosa,  to  a  strict  regimen.  We  may  satis- 
fy ourselves  whether  it  is  owing  to  the  morbid  state  I  have  de- 
scribed, by  examining  the  nature  of  the  discharges.  The  child 
ought  then  to  be  fed  on  milk  and  water  or  barley-water.  The 
diarrha3a  which  supervenes  in  such  cases  is  so  abundant  and  so 
debilitating,  that  in  a  few  days  the  child  is  reduced  to  complete 
marasmus.  The  follicular  development  may  not  be  confined 
solely  to  the  intestines ;  but  it  may  also  occur  in  the  whole 
length  of  the  digestive  tube,  as  will  be  seen  by  the  following  case. 

CASE  XLVII. — Charles  Marand,  aged  six  months,  entered  the  infir- 
mary on  the  8th  of  March.  He  had,  for  some  days,  been  affected  with 
a  diarrhoea,  at  first  of  yellow  matters,  afterwards  white  and  frothy  ;  he 
was  pale,  thin,  and  extremely  feeble  ;  a  great  number  of  small  project- 
ing points  were  seen  in  the  mouth ;  the  tongue  was  dry,  without  be- 
ing red  ;  the  limbs  were  cold  ;  there  was  nothing  remarkable  in  the 
pulse.  (Sweetened  rice-water,  milk  and  water.)  On  the  ninth,  the 
diarrhoea  continued  ;  the  abdomen  was  slightly  tumefied ;  the  child 
cried  but  little  ;  yet  the  face  was  pinched,  and  presented  the  appear- 
ance of  facies  hippocratica.  A  tumefaction  was  observed  on  the 
lower  gum,  produced  by  the  first  incisors,  which  were  ready  to  ap- 
pear ;  an  abundant  saliva  flowed  from  the  mouth,  and  every  thing 


308  ON    THE    DISEASES    OF    INFANTS. 

seemed  to  indicate  that  the  child  was  suffering  from  dentition.  He 
died  on  the  night  of  the  eighth. 

Post  mortem  examination. — The  body  exhibited  a  great  degree 
of  emaciation  ;  the  mouth,  <Esophagus,  and  stomach  presented  a 
great  number  of  small,  white,  slightly  projecting  follicles.  The 
mucous  membrane  of  the  small  intestines  was  pale  and  studded  with 
numerous  follicles,  and  fourteen  well-marked  uninflamed  follicular 
plexuses  were  discovered  in  the  lower  two  thirds  of  the  ileon.  There 
were  but  few  in  the  caecum ;  the  colon  was  pale,  like  the  small  intes- 
tines ;  the  lungs  and  brain  were  healthy. 

Although  the  follicular  apparatus  was  very  much  developed,  it 
certainly  was  not  inflamed  in  the  subject  of  this  case.  The  diarrhoea 
and  the  marasmus  which  were  observed,  were  owing  to  an  abun- 
dant secretion  from  the  intestinal  tube. 


This  disease  is  the  more  serious  in  proportion  as  it  is  compli- 
cated with  encephalitis,  or  aphthous  or  follicular  stomatitis,  as 
is  often  observed  in  dentition.  Children  perish  then  in  a  very- 
short  time,  and  the  abundant  discharges  ought  to  be  arrested; 
and  the  affection  not  being  accompanied  with  inflammation,  as 
we  have  just  seen,  may  be  advantageously  treated  by  using 
slightly  astringent  drinks.  I  am  not  able  to  designate  precisely 
the  mode  of  treatment  which  it  is  necessary  to  pursue,  because 
experience  has  not  enabled  me  either  to  test  any,  or  to  observe 
that  of  others. 

The  follicular  apparatus  may  become,  in  some  instances,  the 
seat  of  evident  inflammation,  such  as  is  met  with  in  adults.  M. 
Denis  was  one  of  the  first  to  describe  this  affection  in  young  in- 
fants ;  and  having  myself  often  had  opportunities  of  studying  the 
disease  at  the  Hospice  des  Enfans  Trouves,  I  am  satisfied  with 
the  correctness  of  M.  Denis's  description. 

When  the  isolated  follicles  or  the  follicular  plexuses  of  the  in- 
testinal tube  become  inflamed,  they  may  exhibit  two  species  of 
alteration.  They  are  either  simply  red  and  tumefied,  or  disor- 
ganized, forming  ulcers  remarkable  both  for  their  form  and  ap- 
pearance. I  will  not  stop  to  follow  them  in  their  various  pe- 
riods of  development,  tumefaction,  and  ulceration,  but  will  re- 
fer to  another  work,  in  which  I  have  given  the  details  in  full, 


ON   THE    DISEASES    OP    INFANTS.  309 

and  confine  myself  here  to  the  examination  of  the  difference  be- 
tween the  disease  as  it  appears  in  children  and  in  adults. 

It  is  well  known  that  inflammation  of  the  follicular  apparatus 
in  adults,  gives  rise  to  symptoms  analogous  to  those  which  are 
assigned  to  putrid  and  adynamic  fevers.  This  has  been  de- 
monstrated by  the  researches  of  MM.  Petit  and  Serres,  and  in 
the  more  recent  work  of  M.  Bretonneau.  What  I  have  published 
on  the  same  subject,  goes  equally  to  the  support  of  this  opinion. 
But  it  is  not  in  every  respect  the  same  in  young  infants,  for  in 
twenty  cases  of  inflammation  of  the  follicular  apparatus  of  the 
intestines  in  young  infants  aged  from  a  few  days  to  two  months, 
I  saw  no  other  symptoms  than  those  of  enteritis.  No  cerebral 
complication,  nor  any  of  the  symptoms  which  have  been  attri- 
buted to  putridity,  appeared  in  these  cases,  which,  however,  ex- 
hibited, on  a  post  mortem  examination,  the  same  anatomical  le- 
sions as  appeared  in  adults.  This,  however,  was  not  the  case  in 
infants  more  advanced  in  age.  The  affection  then  presented  a 
great  analogy  to  that  of  adults.  I  will  endeavor,  in  two  exam- 
ples, to  convey  some  idea  of  this  difference ;  the  description  of 
these  two  cases  will  enable  us  to  obtain  a  knowledge  of  the  ana- 
tomical lesions  which  appertain  to  this  disease. 

CASE  XLVIII. — Meillenet,  a  girl,  aged  twenty-four  days,  enter- 
ed the  infirmary  on  the  2()th  of  January.  She  was  pale,  and  a  little 
emaciated  ;  she  had  been  affected  with  a  copious  diarrhoea  of  green 
matters  for  two  days  previous  ;  the  abdomen  was  tense  and  painful 
to  the  touch  ;  the  tongue  was  red  at  the  point,  and  very  dry  at  the 
base  ;  the  skin  very  hot ;  the  pulse  natural.  (Gummed  rice-water, 
cataplasm  to  the  abdomen,  strict  diet.)  On  the  twenty-seventh,  the 
child  vomited  the  drinks  ;  continued  in  the  same  general  condition, 
but  became  progressively  emaciated.  On  the  1st  of  February,  there 
was  not  quite  so  much  vomiting,  but  the  diarrhoea,  tension  of  the  ab- 
domen, and  emaciation  continued  ;  a  number  of  wrinkles  appeared 
at  the  root  of  the  nose,  and  the  face,  which  until  then  was  without 
expression,  indicated  the  existence  of  pain.  On  the  eighth,  the 
same  general  condition  continued  ;  marasmus  very  much  advanced ; 
diarrhoea  continued  ;  the  discharges  yellow,  and  sometimes  green. 
{Gummed  rice-water,  bath.)  From  the  eighth  to  the  sixteenth, 
there  was  a  rapid  increase  of  symptoms  ;  excessive  weakness  ;  hol- 
lowness  of  the  cheeks,  and  a  projection  of  the  cheek  bones  resem- 


310  ON    THE    DISEASES    OP    INFANTS. 

bling  those  of  an  old  man ;  numerous  wrinkles  on  the  forehead  ; 
skin  of  an  ash-color ;  cry  extremely  feeble.  Death  occurred  on 
the  nineteenth. 

On  examining  the  body  on  the  following  day,  there  appeared  a 
general  paleness  and  emaciation.  The  mouth  and  cesophagus  were 
healthy  ;  stomach  of  a  rosy  hue  ;  some  red  transverse  striae  existed 
about  the  valvulae  conniventes  of  the  small  intestines,  where  were 
also  found  a  number  of  red  projecting  pimples  ;  some  of  them  had 
already  commenced  to  ulcerate.  Eight  follicular  plexuses,  very  red 
and  much  tumefied,  existed  at  the  extremity  of  the  ileon ;  that  which 
terminated  this  intestine  was  also  a  little  excoriated  and  bloody, 
and  the  surface  was  covered  with  a  thick  and  tenacious  mucus.  The 
caecum  was  healthy.  There  existed  at  the  end  of  the  colon  a  large 
number  of  red  striae,  and  a  quantity  of  purulent  mucus  adhering  to 
the  surface  of  the  internal  membrane. 

The  liver  was  dark-colored,  and  filled  with  black  blood  ;  the  gall- 
bladder contained  a  quantity  of  liquid  bloody  bile.  The  right  lung 
was  engorged  with  blood  at  the  posterior  border.  The  brain  was 
very  much  injected;  its  substance  was  of  a  bright  rose-color;  its 
ventricles  contained  a  quantity  of  serum. 

This  child  presented  no  other  symptoms  than  those  ordinarily 
attending  enteritis ;  but  such  was  not  the  case  with  the  follow- 
ing patient. 

CASE  XLIX. — Francois  Tessont,  aged  thirteen  months,  entered 
the  infirmary  on  the  12th  of  September.  For  several  days  he  had 
been  very  restless,  and  had  scarcely  slept ;  the  pupils  were  dilated  ; 
the  tongue  red  and  dry  ;  the  skin  very  hot ;  the  pulse  very  frequent. 
There  was  neither  vomiting  nor  diarrhoea.  (Gummed  barley-wa- 
ter, sinapised  pedeluvium,  cataplasm  to  the  abdomen,  three  leeches 
to  the  epigastrium.)  On  the  thirteenth,  a  very  abundant  diarrhoea 
of  green  liquid  matters ;  abdomen  less  tender ;  child  cried  less  and 
appeared  enfeebled.  From  the  eighteenth  to  the  twentieth,  there 
was  no  change.  On  the  twenty-first,  diarrhoea  less  abundant,  and 
vomiting  supervened.  On  the  twenty-third,  respiration  was  painful, 
and  the  child  exhibited  a  state  of  general  prostration  diflScult  to  de- 
scribe ;  the  face  was  pinched,  and  the  forehead  particularly  exhibit- 
ed a  number  of  wrinkles  which  continued  even  after  the  cries  had 
ceased ;  two  livid  circles  appeared  about  the  alse  of  the  nose ;  the 
pulse  beat  from  ninety  to  a  hundred.     On  the  twenty-fourth,  the 


ON    THE    DISEASES    OF    INFANTS.  311 

same  general  state  ;  the  foeces  were  extremely  foetid  ;  great  prostra- 
tion ;  extreme  marasmus  ;  and  the  pulse  became  evidently  enfeebled, 
although  the  skin  presented  much  of  its  heat.  On  the  twenty-fifth, 
prostration  complete  ;  facies  hippocratica,  convulsive  motion  of  the 
globe  of  the  eye  ;  the  bites  of  the  leeches  had  become  violet ;  they 
ulcerated,  and  a  purulent  sanies  flowed  from  them.  The  ehild  died 
on  the  night  of  the  twenty-sixth.  The  examination  of  the  body  was 
made  on  the  twenty-seventh. 

General  paleness  and  marasmus  ;  an  eschar  of  the  size  of  a  two- 
franc  piece  was  found  on  the  sacrum;  mouth  and  oesophagus 
healthy  ;  slight  redness  of  the  stomach.  In  the  duodenum  andileon 
there  were  found  a  large  number  of  glands,  red  and  tumefied  ;  some 
of  them  were  open,  and  exhibited  in  their  centres  superficial  ulcera- 
tions. Twelve  follicular  plexuses,  very  red  and  tumefied,  existed  at 
the  end  of  the  ileon.  In  the  colon  and  caecum  there  were  a  great 
number  of  isolated  follicles  about  the  size  of  a  hemp-seed,  and 
which,  instead  of  being  red  like  those  in  the  ileon,  were,  on  the  con- 
trary, surrounded  with  a  blue  circle.  The  circulatory  and  respira- 
tory apparatuses  presented  nothing  worthy  of  remark.  The  brain  was 
injected,  and  contained  in  its  ventricles  a  quantity  of  slightly  turbid 
serosity.     The  spinal  marrow  was  healthy. 

I  have  selected  these  two  cases  from  a  number  in  my  posses- 
sion, because  they  exhibit  a  remarkable  antithesis  with  respect  to 
their  symptoms,  while  there  can  be  nothing  more  remarkable 
than  the  resemblance  in  their  pathology.  The  difference  of  age 
between  these  two  children  can  explain,  without  doubt,  the  dif- 
ference of  symptoms.  Indeed,  we  almost  always  see  that  reac- 
tion is  very  trifling  in  young  infants,  although  their  lesions  may 
be  very  serious ;  but  in  proportion  as  they  advance  in  age,  we 
are  able  to  observe  all  the  general  symptoms  depending  on  the 
sympathetic  relations  which  exist  between  the  different  organs 
of  the  system.  This  observation  will  be  more  fully  developed 
when  we  consider  the  history  of  the  diseases  of  the  cerebro- 
spinal apparatus. 

From  the  preceding  facts  and  considerations,  it  results  that 
follicular  enteritis  is  not  to  be  distinguished  by  its  symptoms  from 
ordinary  enteritis,  except  in  children  already  advanced  in  age; 
that  in  very  young  infants,  inflammation  of  the  muciparous 
glands  of  the  intestinal  tube,  although  of  frequent  occurrence, 


312  ON   THE    DISEASES    OF    INFANTS. 

does  not  give  rise  to  any  remarkable  symptoms  either  in  their 
progress,  their  pecuUar  characters,  or  their  comphcations ;  it  is 
not  until  about  the  seventh,  eighth,  or  tenth  month  that  this  in- 
flammation produces  any  particular  symptoms,  the  assemblage 
of  which  constitutes  the  disease  described  under  the  name  of 
entero-mesenteric  fever  by  MM.  Serres  and  Petit,  and  dothin- 
enteritis  by  M.  Bretonneau. 

Chronic  inflammation  of  the  follicular  apparatus  is  met  with 
sometimes,  but  rarely  in  infants  at  the  breast.  This  inflamma- 
tion is  seen  principally  when  there  exists  tubercles  in  the  lungs, 
or  when  the  mesenteric  glands  inflame,  become  engorged  and 
disorganized. 

Enteritis  with  disorganization  of  tissue. — Under  this  subdi- 
vision I  arrange  the  inflammatory  softening  and  gangrene  of  the 
intestines. 

The  inflammatory  softening  must  not  be  confounded  with  the 
white  softening  of  the  intestinal  mucous  membrane.  It  is  the 
former  only  that  we  are  now  to  consider. 

When  the  mucous  membrane  has  been  a  long  time  the  seat  of 
a  phlegmasia,  the  stimulus  of  which  has  continually  maintained 
the  blood  in  its  tissue,  it  acquires  at  first  a  great  degree  of  friabili- 
ty ;  it  is  easily  torn  with  the  nail,  and  when  this  friable  condition 
is  kept  up  by  a  continued  afflux  of  blood,  it  persists  for  some 
time,  and  the  membrane  becomes  disorganized  so  as  to  exhibit 
but  few  traces  of  its  membranous  structure  ;  and  when  we  en- 
deavor to  separate  it  from  the  other  membranes,  it  is  found  to  be 
a  soft  and  reddish  mass.  This  disorganization  ought  to  be  con- 
sidered as  of  a  very  serious  nature,  particularly  when  it  occupies 
a  ofeneral  extent  of  the  intestinal  surface.  All  the  children 
which  have  exhibited  the  disease,  have  experienced  during  life 
the  most  serious  symptoms  of  enteritis  ;  but  showing  no  external 
evidence  by  which  the  existence  of  this  alteration  could  be 
known.  I  shall,  on  this  account,  give  no  examples  of  it  here  ; 
for  we  would  but  see  the  collection  of  symptoms  of  enteritis  al- 
ready exhibited,  of  which  this  softening  is  one  of  the  fatal  termi- 
nations. 

Gangrene  of  the  mucous  membrane  of  the  intestines  equally 
deserves  our  attention  ;  it  appears  under  different  aspects.  Thus 
we  see  certain  ulcerations  of  the  ileo-csecal  region,  exhibiting 


ON    THE    DISEASES    OF    INFANTS.  313 

their  edges  black  like  soot,  and  like  that  which  is  observed  on 
ulcerated  aphthss  of  the  mouth.  Some  circumscribed  points  of 
the  mucous  membrane  may  ulcerate  and  become  gangrenous, 
without  inflammation  having  preceded  this  ulceration,  and 
which  always  commences  in  the  following  manner,  as  described 
by  Cloquet;  a  black  line  appears,  about  which  the  mucous  mem- 
brane changes  to  a  gray  pulp.  The  eschars  which  then  form, 
soon  separate,  and  are  followed  by  an  ulcer  v/ith  a  projecting 
edge,  the  bottom  of  which  is  destroyed  so  as  to  produce  a  com- 
plete perforation..  This  occurrence  is  of  a  very  serious  nature, 
for  it  may  give  rise  to  the  escape  of  the  contents  of  the  intestines 
into  the  abdomen.  Adhesions  are  often  very  promptly  formed  be- 
tween the  intestines,  which  sometimes  prevents  this  eiFusion.* 
I  have  not  had  an  opportunity  of  seeing  this  species  of  gangre- 
nous ulcerations  in  infants  at  the  breast ;  yet  Cloquet  has  met 
with  it  in  children  of  a  very  tender  age. 

As  to  gangrene  produced  by  excess  of  inflammation,  and  which 
occupies  a  greater  or  less  extent  of  the  intestines,  it  is  some- 
times to  be  seen  in  young  infants.  ■  I  shall  give  a  very  remarka- 
ble example  which  occurred  in  a  young  infant,  and  where,  dur- 
ing life,  all  the  symptoms  of  dysentery  existed. 

CASE  L. — Enteritis,  gangrene  of  the  colon. — Caroline  Jossey, 
aged  nine  days,  small  and  feeble,  entered  the  infirmary  on  the  7th. 
of  November.  She  exhibited  a  general  redness  of  the  integuments, 
and  an  (edematous  swelling  of  the  limbs  ;  the  heat  of  the  skin  was 
natural ;  the  cry  exhibited  no  alteration ;  the  pulse  was  regular,  beating 
ninety-two  in  a  minute.  This  child  was  attacked  with  a  copious  green 
diarrhoea.  An  intense  redness  was  observed  about  the  anus  :  the  abdo- 
men was  distended.  On  the  twelfth  there  appeared  several  streaks  of 
blood  in  the  green  discharges  from  the  bowels,  which  occasionally 
consisted  of  black  pitchy  matters ;  the  general  condition  was  the  same. 
(Sweetened  rice-water,  starch  injections,  milk  and  water.)  On  the 
thirteenth,  the  limbs  were  not  so  much  swelled,  the  face  was  pale, 
the  commissure  of  the  lips  was  drawn  backwards,  the  forehead  very 
much  wrinkled,  particularly  at  the  nose ;  the  pulse  was  extremely 
small  and  feeble  ;  the  bloody  diarrhoea  continued,  and  froth  issued 
at  the  mouth.  On  the  fourteenth,  a  large  quantity  of  blood  passed  from 

*  Nouveau  journal  demed.  by  Bedaid,  Cloquet,  etc.   torn,  1,  January,  1818. 

40 


314  ON   THE    DISEASES    OP    INFANTS. 

the  bowels  ;  the  face  became  thin  and  livid  ;  the  drinks  were  vomit- 
ed with  a  quantity  of  filamentous  mucus.  The  limbs  were  coJd  and 
livid  ;  the  abdomen  contracted  ;  the  pulsations  of  the  heart  extremely 
slow.  She  died  at  night,  while  passing  a  large  quantity  of  liquid  black 
blood. 

On  examining  the  body  the  following  day,  a  number  of  sugilla 
tions  were  found  on  the  back  and  nates.  There  was  a  thick  layer 
of  yellow  mucus  on  the  tongue,  a  very  great  congestion  of  the  oeso- 
phagus, and  a  spotted  redness  of  the  stomach.  The  duodenum  was 
healthy  ;  at  the  extremity  of  the  ileon  there  existed  an  intense  red- 
ness, with  tumefaction  and  friability  of  the  mucous  tissue,  and  san- 
guineous exhalation  on  its  surface.  The  mucous  membrane  of  the 
caecum  and  colon  was  remarkable  for  its  thickness  and  its  intense 
redness  ;  it  was  covered  with  blood  throughout  its  whole  extent. 
When  this  was  removed,  the  membrane  appeared  rugous  and  bloody  ; 
its  surface  was  furrowed  with  a  number  of  wrinkles,  between  which 
there  appeared  several  excoriated  and  black  lines,  as  if  they  had  been 
burned  with  nitric  acid.  Besides  these  furrows,  there  were,  at  dif- 
ferent parts  of  the  colon,  a  large  number  of  ecchymosed  spots  of  the 
same  appearance.  The  mucous  membrane  was  so  soft  about  these 
points,  that  it  easily  separated  with  the  nail.  This  condition  was 
particularly  remarkable  about  the  rectum,  where  was  found  a  large 
quantity  of  blood  mixed  with  membranous  shreds  of  a  black  color. 
This  intestine  diffused  an  evident  gangrenous  odor. 

The  liver  was  gorged  with  blood ;  the  lungs  were  healthy ;  the 
foetal  openings  obliterated  ;  the  brain  much  injected. 

Entero-colitis  could  hardly  have  been  more  violent  than  in  this 
case.  The  gangrene  of  the  large  intestines  was  doubtless  the 
result  of  inflammation,  and  of  the  great  afiiux  of  blood  which 
took  place  to  the  part;  the  general  prostration  and  intestinal 
hemorrhage  were  here  the  only  peculiar  characteristics  of  this 
enteritis,  which  exhibited,  besides,  the  ordinary  symptoms  of  in- 
flammation of  the  intestines. 

All  the  varieties  of  intestinal  inflammation  have  now  passed  in 
review.  We  have  pointed  out,  as  far  as  possible,  the  peculiar 
symptoms  of  each  of  these  varieties  ;  and  it  now  remains  to  study 
the  phlegm asias  of  the  mucous  membrane  with  reference  to  their 
seat. 

From  the  most  remote  antiquity,  the  diseases  of  the  small  were 


ON   THE    DISEASES    OF    INFANTS.  3l5 

distinguished  from  those  of  the  large  intestines.  Celsus  has  ob- 
served that  this  distinction  was  long  before  made  known  by  Dio- 
des. "  Diodes  Carystias  tenuioris  intestini  morbiim,  xk^ci-<^av^ 
pleniorisj  uXi^v  nominavit.  A  plerisque  video  nimc  illiim  prio- 
rem  eloXehv,  hunc  xoXtxov  nominari."  In  dividing  then,  at  the 
present  day,  the  diseases  of  the  intestinal  tube  into  two  sections, 
we  follow  a  method  supported  by  the  experience  and  authority 
of  the  most  ancient  authors. 

But  an  important  question  here  arises  ;  is  it  easy  to  distinguish 
in  very  young  infants,  during  life,  inflammation  of  the  small  in- 
testines from  those  of  the  large?     We  will  answer  by  facts. 

I  will,  in  the  first  place,  observe  that  it  has  always  been  im 
possible  for  me  to  establish  a  well-marked  distinction  between  in- 
flammation of  the  duodenum,  and  that  of  the  rest  of  the  small 
intestines,  in  nursing  children,  and  I  will  on  this  account  use  the 
more  general  term  enteritis  or  ileitis,  to  distinguish  the  inflam- 
matory aflection  of  the  small  intestines ;  and  will  denominate  that 
of  the  large,  colitis. 

In  eighty  cases  of  inflammation  of  the  intestines  that  I  ex- 
amined with  great  care,  there  were  thirty  of  entero-colitis,  thirty- 
six  of  enteritis,  and  fourteen  of  colitis. 

In  the  thirty  cases  of  entero-colitis,  there  were  twenty  with 
diarrhoea  of  yellow  or  green  matters  ;  in  the  other  ten,  the  diar- 
rhoea was  not  noted.  In  all,  there  was  a  distension  of  the  abdo- 
men, which  was  more  or  less  painful  on  pressure.  In  twelve  of 
these  children  there  was  vomiting  of  yellow  matters,  although 
there  existed  no  gastritis.  In  all,  there  was  an  ery thematic  red- 
ness about  the  anus,  of  greater  or  less  intensity ;  caused,  doubt- 
less, by  the  abundance  and  contact  of  the  alvine  dejections. 
The  tongue  was  very  often  red  and  dry  ;  the  skin  very  hot  and 
arid  ;  but  the  pulse  was  rarely  raised  to  the  degree  that  generally 
indicates  fever  ;  in  several  of  the  cases  the  pulsations  were  feeble 
and  slow. 

In  the  thirty-six  cases  where  the  small  intestines  alone  were 
affected,  there  were  twenty  instances  of  vomiting,  either  of  drinks 
or  of  intestinal  matters ;  and  among  twenty  cases  of  vomiting, 
the  inflammation  was  seated  in  the  ileo-cgecal  region,  and  even  at 
the  valve,  in  fifteen  instances ;  it  is  possible,  therefore,  that  the 
obstruction  resulted  from  the  tumefaction  of  this  valve,  and  this 


316  ON    THE    DISEASES    OF    INFANTS. 

consequently  produced  an  interruption  in  the  course  of  the  intes- 
tinal matters,  followed  by  vomiting.  In  every  instance  the  abdo- 
men was  tumefied,  if  not  at  the  commencement  of  the  disease,  at 
least  during  its  course.  There  were  twenty-five  instances  of  di- 
arrhoea, consisting  of  yellow,  and  often  of  green  matters,  analo- 
gous to  the  meconium;  the  tongue  was  almost  always  red  ;  the 
skin  hot ;.  the  pulse  but  little  disturbed,  except  in  two  infants, 
considerably  advanced  in  age,  one  of  whom  had  a  very  severe 
inflammation  of  the  muciparous  follicles.  I  also  noticed  a  red- 
ness about  the  anus  of  all. 

Lastly,  there  existed  a  diarrhoea  in  fourteen  affected  with  coli- 
tis ;  the  tympanitic  state  of  the  abdomen  was  in  general  less  ;  in 
six  cases  only,  was  there  vomiting,  and  I  often  observed  a  very 
remarkable  dryness  of  the  integuments,  which  in  general  were 
cold  and  livid.  The  pulse  was  not  quicker  than  in  the  preceding 
case. 

The  eighty  children  forming  the  subjects  of  this  analysis, 
were,  for  the  most  part,  aged  from  one  day  to  six  months ;  some 
were  from  the  age  of  six  months  to  a  year. 
.  From  this  calculation,  it  is  evidently  very  difficult  to  make  a 
correct  diagnosis  of  inflammation  of  the  intestinal  tube  in  suck- 
ing infants,  yet  it  would  seem  as  if  the  proper  signs  of  enteritis 
or  ileitis  were  the  rapid  tympanitis  of  the  abdomen,  the  diarrhoea 
accompanied  with  vomiting ;  while  in  colitis,  diarrhoea  alone,  with- 
out tympanitis,  is  the  most  frequent. 

The  complication  of  gastritis  with  enteritis,  or  gastro-enteritis, 
is  extremely  common  in  young  infants  ;  the  predominance  of  the 
symptoms  peculiar  to  gastritis,  and  which  have  already  been  de- 
scribed, will  alone  enable  us  to  suspect  the  existence  of  this  com- 
plication. 

In  the  impossibility  of  tracing  with  exactness  the  series  of 
symptoms  peculiar  to  inflammation  of  each  of  the  parts  of  the 
digestive  tube,  we  shall  only  present  an  analysis  of  the  causes, 
symptoms,  and  ordinary  progress  of  inflammation  of  the  mu- 
cous membrane  of  the  intestines  in  general. 

Causes. — The  injection  of  the  intestinal  tube  at  birth,  the  fa- 
cility with  which  this  apparatus  becomes  injected,  producmg 
very  considerable  congestion  upon  the  slightest  disturbance  oc- 
curring in  the  course  of  the  blood  in  the  thoracic  and  abdomi- 


ON   THE    DISEASES    OF    INFANTS.  317 

nal  vessels,  the  ingestion  of  aliments  too  stimulant,  too  nutritious, 
or  too  difficult  to  digest ;  and  lastly,  the  functional  activity  of 
the  digestive  apparatus  from  birth,  are  the  numerous  causes  of 
inflammation  of  the  digestive  passages  of  young  infants.  The 
activity  of  these  various  morbid  causes,  easily  explains  the  fire- 
quency  of  diseases  of  the  digestive  organs  of  young  children. 
Of  all  the  affections  to  which  tiiey  are  liable,  these  are  the  most 
numerous  and  most  fatal ;  we  should,  on  this  account,  exert  the 
utmost  care  in  directing  and  superintending  the  mode  of  alimen- 
tation to  which  nursing  children  are  subjected. 

The  diseases  of  the  digestive  tube  do  not  always  present,  at 
the  commencement,  a  well-marked  inflammatory  character ;  at 
first,  they  frequently  are  only  simple  passive  congestions  ;  but  the 
continuance  of  the  blood  in  the  tissue  of  the  mucous  membrane, 
really  excites  inflammation,  as  is  observed  in  old  people,  or  in 
those  individuals  affected  with  diseases  of  the  heart  and  large 
vessels. 

Symptoms. — The  symptoms  of  diseases  of  the  digestive  passa- 
ges in  young  infants  are  almost  always  local ;  they  do  not  give 
rise  to  symptoms  of  reaction  such  as  is  observed  in  adults,  ex- 
cept as  the  children  advance  in  age.  We  ought,  therefore,  par- 
ticularly to  direct  our  attention  to  the  disturbance  of  the  diges- 
tive functions,  when  we  wish  to  make  a  correct  diagnosis  of  the 
diseases  of  the  intestines. 

Vomiting  is  very  frequent  in  enteritis,  but  it  generally  presents 
this  peculiarity,  that  the  matters  vomited  are  yellow  and  frothy, 
and  that  it  does  not  occur  immediately  after  the  ingestion  of 
drinks.  Diarrhosa  almost  invariably  exists  ;  the  discharges  are 
green  and  yellow,  and  are  rarely  serous.  In  the  latter  case  it  is 
generally  owing  to  an  increase  of  secretion,  caused  by  functional 
activity  and  a  morbid  development  in  the  follicular  apparatus  of 
the  intestines.  The  tympanitis  and  tension  of  the  abdomen,  its 
pain  on  pressure,  are  also  remarkable,  and  almost  constant  signs 
of  enteritis.  Unite  to  these  symptoms,  those  of  redness  and 
dryness  of  the  tongue,  heat  of  the  integuments,  but  which,  to- 
wards the  end  of  the  disease,  become  cold  and  icy — lastly,  erythe- 
ma of  the  anus  and  surrounding  skin,  and  then  we  have  the  most 
common  symptoms  of  gastro-enteritis,  and  of  entero-colitis. 

While  these  symptoms  successively  succeed  each  other,  and 


318  ON    THE    DISEASES    OF    INFANTS. 

the  disease  which  causes  them  is  making  its  progress,  the  child 
falls  into  a  complete  marasmus,  the  integuments  assume  an  ashy- 
aspect,  the  osseous  projections  become  more  evident  than  is  usual 
at  this  age,  the  fat  of  the  cheeks  disappears,  and  they  become 
hollowed  ;  the  orbits  are  sunken  like  those  of  old  people ;  the 
face  acquires  the  same  old  appearance  which  is  observed  in 
adults,  arising  doubtless  from  the  absence  of  the  teeth,  which,  in 
the  infant,  as  well  as  in  the  old  man,  gives  the  physiognomy  an 
expression  altogether  different  from  that  of  adults  who  still  re- 
tain the  two  dental  arches.  Lastly,  several  lineaments  are  seen 
upon  the  face,  which  we  will  endeavor  to  compare  with  those 
w^hich  M.  Jadelot  has  pointed  out  in  children  of  a  more  ad- 
vanced age. 

M.  Jadelot  describes  the  nasal  lineament  as  appearing  on  the 
inside  of  the  alse  of  the  nose,  and  embracing  the  whole  of  the  or- 
bicularis oris  muscle  ;  and  the  genal  lineament,  that  which  ex- 
tends from  the  commissure  of  the  lips,  and  loses  itself  near  the 
lower  part  of  the  face  :  he  regards  both  these  as  a  symptom  of 
abdominal  affections.  In  very  young  infants,  although  these 
signs  are  not  observable  with  great  distinctness,  yet  they  are  still 
to  be  seen  in  some  degree.  The  commissure  of  the  lips,  for  in- 
stance, as  I  have  often  indicated  in  the  cases  mentioned,  is  drawn 
outward,  thus  causing  a  fold  of  skin  more  or  less  prominent  on 
the  outside  of  the  orbicularis  oris  muscle  ;  there  is  also  formed 
another  fold,  very  analogous  to  the  genal  lineament,  which  is  di- 
rected from  the  inferior  lip  towards  the  chin ;  this,  however,  is 
less  frequently  seen  than  the  preceding.  Other  folds  of  the  skin 
which  are  constantly  to  be  observed  in  abdominal  affections,  and 
which  are  also  noticed  under  all  circumstances  where  the  child 
experiences  violent  pains,  are  remarked  at  the  root  of  the  nose 
and  in  the  forehead.  The  skin  at  this  part  presents  a  wrinkled 
aspect,  and  a  well-marked  indication  of  distress  which  ought  not 
to  be  neglected.  I  have  always  been  struck  with  the  coinci- 
dence of  these  irregular  wrinkles  on  the  skin  of  the  forehead, 
with  the  existence  of  an  inflammation  of  the  digestive  passages 
Altogether  these  traits  give  to  the  physiognomy  of  the  child  an 
expression  known  ordinarily  by  the  name  of  "face  grippee ;'' 
this  expression  is  always  an  index  of  a  violent  gastro-intestinal 
phlegmasia. 


ON    THE    DISEASES    OF    INFANTS.  319 

Treatment. — The  treatment  of  enteritis  and  of  gastro-enteri- 
tis  ought  to  be  grounded  on  the  doctrines  we  have  advanced  in 
this  article.  We  have  seen  that  a  sanguineous  congestion  of  the 
abdomen  is  often  the  primary  cause  of  phlegmasia  of  the  in- 
testinal tube ;  when  we  are  called,  therefore,  to  prescribe  for  en- 
teritis at  its  commencement,  the  application  of  one  or  two  leeches 
to  the  anus  ought  not  to  be  neglected,  particularly  if  there  be 
any  signs  of  sanguineous  plethora  present.  Abstinence  from  the 
breast  is  very  necessary,  and  the  use  of  mucilaginous  and  de- 
mulcent drinks,  such  as  a  sweetened  decoction  of  marshmallows, 
milk  diluted  with  barley-water,  etc.,  ought  to  be  substituted.  If 
the  child  appear  to  suffer  much,  and  if  the  diarrhoea  be  very 
abundant,  enemeta  of  starch,  with  from  four  to  eight  drops  of 
laudanum,  ought  to  be  administered.  Preparations  of  opium 
ought  to  be  given  to  young  children  with  great  caution,  for  their 
action  is  much  greater  on  them  than  on  adults  ;  it  would  even 
appear  as  if  the  absorbent  function  of  the  rectum  is  in  a  greater 
degree  of  activity.  1  have  often  seen  infants,  from  the  age  of 
eight  to  twelve  days,  almost  completely  narcotized  by  six  drops 
of  laudanum  introduced  into  the  rectum  by  an  enema.  Three 
to  four  ounces  of  fluid  is  sufficient  as  an  enema  for  very  young 
children.  A  larger  quantity  distends  the  intestines,  and  forces 
them  to  return  the  fluid  before  it  has  had  time  to  produce  any 
effect.  On  no  account  should  the  application  of  cataplasms  to 
the  abdomen  be  omitted.  The  greatest  benefit  will  arise  from 
the  use  of  emollient  baths,  and  nothing  so  soon  arrests  their  cries 
and  their  pain ;  for  they  often  become  so  tranquillized  as  to  fall 
asleep  as  soon  as  they  are  immersed  in  the  bath.  The  hours  of 
feeding,  and  the  quantity  of  aliment,  ought  particularly  to  be 
regulated. 

Before  concluding  my  remarks  on  phlegmasise  of  the  gastro- 
intestinal mucous  membrane,  there  still  remains  a  question  for 
me  to  examine.  Do  the  violent  pains  of  the  bowels  experienced 
by  an  infant,  for  a  greater  or  less  time  after  birth,  arise  from  an 
inflammation  of  the  digestive  passages  ? 

I  believe  that  these  colic  pains  may  arise  from  several  different 
causes.  These  are — 1st,  The  difficulty  of  the  first  al  vine  evacua- 
tions. The  retention  of  the  meconium,  for  instance,  may  cause 
violent  pains  in  infants,  analogous  to  those  which  are  experienced 


320  ON    THE    DISEASES    OF    INFANTS. 

after  a  long  and  obstinate  constipation.  This  is  what  we  have 
seen  in  children  affected  with  an  imperforate  anus.  In  these 
cases,  the  alvine  evacuations  ought  to  be  excited  by  means  of  in 
jections  with  olive  oil,  or  castor  oil.  Two  drachms  is  sufficient, 
in  two  ounces  of  tepid  water.  A  suppository  of  soap  might 
also  be  introduced  into  the  rectum.  It  would  be  proper,  like- 
wise, to  give  the  child  one  or  two  tea-spoonfuls  of  syrup  of 
rhubarb  or  chicory.  2dly,  I  have  examined,  after  death,  the 
bodies  of  a  number  of  infants  that  have  been  affected  with  colic, 
or  sharp  pains,  after  their  birth,  where  I  have  almost  always 
found,  either  a  congestion,  or  more  often  an  inflammation  of  the 
intestinal  tube  ;  it  would  appear,  therefore,  that  abdominal  pains, 
the  restlessness  and  cries  which  they  produce,  are  probably  the 
result  of  phlegmasia  of  the  intestines.  3dly,  The  pains  may 
be  caused  by  ileus  or  peritonitis ;  whence  it  follows  that  it  is 
impossible  to  establish,  in  a  general  manner,  a  treatment  for  colic 
of  young  infants,  because  the  causes  which  produce  it  may  vary 
almost  to  an  infinite  degree. 

It  would  appear,  nevertheless,  that  infants  are  liable  to  certain 
spasms  of  the  intestines,  of  which  authors  have  vaguely  spoken 
in  their  works.  It  is  to  be  regretted  that,  for  the  most  part,  they 
have  not  accompanied  their  descriptions  with  an  account  of  the 
post  mortem  appearances  ;  we  shall  endeavor,  however,  to  ob- 
tain a  knowledge  of  what  is  meant  by  this  term. 

Art.  3. — Spasm  of  the  Intestines. 

The  intestines,  after  birth,  sometimes  become  extremely  irrita- 
ble, and  are  affected  with  spasms,  in  consequence  of  which  the 
digestive  functions  are  completely  disturbed;  sometimes  alsoge-. 
neral  convulsions  or  spasmodic  movements  of  the  face  and  limbs 
occur.  It  is  often  impossible  to  understand  the  cause  of  these 
convulsions,  which  frequently  cease  and  reappear  with  greater 
intensity  at  a  period  more  or  less  remote  from  the  appearance  of 
the  first  symptoms.  These  symptoms  are  as  follows  :  the  abdo- 
men swells,  the  child  cries  acutely,  the  face  is  contracted,  the 
limbs  are  stiffened,  the  bowels  are  very  tender  to  the  touch,  the 
alvine  evacuations  are  suspended,  and  vomiting  sometimes  super- 
venes.    I   have  seen  infants   seized   with  these  nervous  colics 


ON    THE    DISEASES    OP    INFANTS.  321 

while  sucking ;  they  quitted  the  breast  abruptly,  cried  suddenly 
and  violently  ;  the  abdomen  swelled  immediately,  and  their  agi- 
tation did  not  cease  until  a  quantity  of  gas  had  escaped  by  the 
anus. 

Dr.  Joseph  Parrish,  one  of  the  physicians  of  the  Pennsylvania 
Hospital  at  Philadelphia,  has  published  in  the  North  American 
Medical  and  Surgical  Journal  a  very  interesting  article  on  this 
subject  .*  It  is  probable,  he  observes,  that  this  spasmodic  affec- 
tion has  its  seat  in  the  intestines,  and  particularly  in  the  muscu- 
lar fibres.  Children  experience  a  very  great  relief  upon  the  ex- 
pulsion of  gas,  which  is  contained  in  the  intestinal  tube  in  such 
quantities  as  to  give  rise  to  a  true  tympanitis.  In  one  case  that 
I  saw  in  1821,  says  Dr.  Parrish,  death  enabled  me  to  verify 
my  views  on  the  cause  of  this  affection  by  dissection. 

"  The  subject  of  this  attack  was  an  infant  about  five  months 
old.  The  convulsions  came  on  instantaneously,  without  the 
least  warning,  and  immediately  after  they  had  passed,  the  patient 
was  quite  sensible  and  even  playful.  At  first,  several  days  inter- 
vened between  the  fits ;  and,  contrary  to  the  general  rule,  they 
came  on  at  one  stated  time,  about,  or  a  Itttle  after,  daybreak. 
They  afterwards  became  more  frequent  and  distressing,  and  to- 
wards the  close  of  the  case,  several  spasms  or  partial  convulsions 
occurred  at  intervals,  the  child  screaming  out,  and  appearing  to 
be  much  in  pain.  The  treatment  was  principally  directed  to  the 
bowels ;  but  leeches  were  twice  applied  to  the  head,  and  blisters 
were  placed  behind  the  ears.  Though  relief  was  occasionally 
obtained,  yet  no  permanent  impression  was  produced  upon  the 
disease,  and  notwithstanding  all  my  efforts,  the  little  sufferer  ex- 
pired. Upon  dissection,  the  bowels  exhibited  strong  evidence  of 
having  been  under  the  influence  of  severe  spasm.  More  than 
half  of  the  small  intestines  were  irregularly  contracted.  In  some 
places,  for  more  than  an  inch  in  extent,  the  bowel  was  reduced  to 
the  size  of  a  goosequill ;  in  others,  it  appeared  as  if  tied  by  a 
thread,  its  calibre  being  almost  obliterated.  The  omentum  was 
closely  folded  up  in  the  form  of  a  thick  twine  or  small  rope, 
and  lay  on  the  arch  of  the  colon.     In  the  gall-bladder  was  a 

♦  On  infantile  convulsions  arising  from  spasm  of  the  intestines.    N.  A.  Med.  &  Surg. 
Journal,  January,  1827. 


322  ON   THE    DISEASES    OF    INFANTS. 

light-colored  and  glairy  fluid.  No  other  sign  of  disease  was  visi- 
ble in  the  cavity  of  the  abdomen  and  thorax.  The  condition  of 
the  brain  I  did  not  examine." 

It  is  evident  there  had  been  spasmodic  contraction  of  the  in- 
testinal tube  ;  but  it  is  unfortunate  that  the  brain  was  not  open- 
ed, because  there  perhaps  the  cause  of  the  spasmodic  disease 
might  have  been  found,  which  perhaps  was  but  a  secondary  af- 
fection. 

The  formation  of  gas  in  the  intestines  often  gives  rise  to  symp- 
toms nearly  resembling  those  which  we  have  just  pointed  out ; 
they  cease  as  soon  as  the  gas  is  expelled,  thus  proving  that  this 
is  the  true  cause. 

In  the  treatment  of  this  disease,  two  things  ought  to  be  con- 
sidered :  the  nervous  excitement,  which  produces  it.  and  the  dis- 
turbance of  the  digestive  organs  which  follows.  The  spasm  of 
the  intestines  is  evidently  owing  to  an  irritation  of  the  cerebro- 
spinal apparatus,  which  must  first  be  attended  to  in  the  treat- 
ment ;  two  or  four  leeches  should  therefore  be  applied  to  the  mas- 
toidean  region,  or  blood  be  taken  from  the  arm  or  foot.  The  ap- 
plication of  leeches  is  preferable  to  general  blood-letting,  if  the 
cerebral  irritation  be  owing  to  an  accumulation  of  blood  about 
the  head,  and  if  the  extreme  feebleness  of  the  patient  appear  to 
counter  indicate  general  bleeding.  At  the  same  time  warm  baths 
should  be  used,  for  they  are  excellent  antispasmodics. 

Among  the  antispasmodics,  asafoetida  has  been  recommended 
to  be  given  in  injections  ;  this  might  be  assisted  by  adding  a  lit- 
tle laudanum ;  two  to  five  grains  of  asafoetida  with  two  or  three 
drops  of  laudanum,  will  be  sufiicient  for  an  injection.  Dr.  Par- 
rish  recommends  the  rubbing  of  the  spinal  region,  fit  the  same 
time,  with  a  liniment  composed  of  a  tea-spoonful  of  oil  of  amber 
and  laudanum  in  a  table-spoonful  of  olive  oil  and  alcohol.  He 
considers  the  irritation  of  the  gums  produced  by  dentition,  as  one 
of  the  causes  of  this  spasmodic  affection,  and  therefore  recom- 
mends us  to  examine  the  condition  of  the  gums,  to  cut  them,  and 
thus  to  allay  the  irritation  in  the  mouth.  But  if  dentition,  and 
the  consequent  irritation  of  the  gums,  be  the  predisposing  cause 
of  the  intestinal  spasm,  it  is  not  excited  however  until  after  hav- 
ing sympathetically  irritated  the  brain,  and  the  nervous  system 
ought  therefore  to  be  attended  to  first. 


ON    THE    DISEASES    OF    INFANTS.  323 

The  removal  of  the  constipation  ought  not  to  be  forgotten,  by 
which  also  the  expulsion  of  gas  is  effected.  Gentle  laxatives,  the 
introduction  of  a  suppository  of  soap  into  the  rectum,  will  accom- 
plish this  object.  Dr.  Parrish  has  removed  the  gas  by  introdu- 
cing an  empty  syringe  into  the  rectum,  and  then  pumping  out 
the  air.  A  gum  elastic  tube  might  be  passed  into  the  intestines, 
by  which  the  air  could  escape  while  compression  is  gently  made 
on  the  abdomen.  I  have  not  considered  this  affection  at  length, 
because  it  appeared  to  me  to  belong  more  particularly  to  the  dis- 
eases of  the  nervous  system,  of  which  we  shall  hereafter  treat. 

Art.  4. — WMte  Softening  of  the  Gastro-intcstinal  Mucous  Membrane. 

I  did  not  speak  of  this  alteration  of  the  mucous  membrane  im- 
mediately after  inflammation,  because  I  have  not  seen  it  as  the 
result  of  inflammation. 

We  have  already  seen  that,  in  consequence  of  bad  or  imperfect 
nutrition,  children  often  become  pale,  sink  into  a  state  of  maras- 
mus, and  die.  Upon  opening  the  bodies  of  these  children,  the 
mucous  membrane  is  found  pale  and  colorless,  like  the  external 
inteofuments.  Now  this  state  of  the  internal  membrane  of  the  di- 
gestive  tube  is  the  first  stage  of  softening  of  the  intestines,  a  soft- 
ening which  must  not  be  confounded  with  that  which  is  pro- 
duced by  an  afflux  of  blood  in  the  mucous  membrane  in  conse- 
quence of  the  iritlammation  developed  in  it. 

The  softening  appears  then  in  two  stages,  that  in  which  the 
membrane  is  only  discolored ;  here  the  mucous  tissue  does  not 
present  its  proper  consistence  ;  it  is  raised  with  the  greatest  ease 
when  scratched,  but  the  shreds  are  still  membranous.  Notwith- 
standing this,  it  may  be  destroyed  with  facility.  In  this  case, 
the  mucous  membrane  presents  still  here  and  there  a  mottled  red, 
which  are  the  last  traces  of  its  normal  color,  or  of  the  accidental 
redness  of  which  it  is  the  seat,  as  was  the  case  in  the  followinsr 
subject. 

CASE  LI. — ^Fanny  Bombardy,  aged  ten  days,  entered  the  infir- 
mary on  the  16th  of  November.  She  was  robust,  skin  of  a  vermil- 
ion color,  and  she  exhibited  an  induration  of  the  cellular  tissue  of 
the  superior  and  inferior  extremities.  From  the  sixteenth  to  the 
twentieth,  the  oedema  of  the  limbs  disappeared,  but  vomiting  and  co- 


324 


ON    THE    DISEASES    OP    INFANTS. 


pious  diarrhoea  supervened.  Some  points  of  muguet  appeared  on 
the  edges  of  the  tongue.  On  the  twenty-fifth,  the  muguet  disappear- 
ed ;  the  diarrhoea  continued,  and  the  child  constantly  passed  a  quan- 
tity of  yellow  frothy  matters.  She  became  pale  and  emaciated.  On 
the  thirtieth,  there  was  a  rapid  progress  of  emaciation  ;  a  universal 
discoloration  of  the  integuments,  which  were  of  a  very  remarkable 
chlorotic  paleness.  The  child  was  without  fever  ;  cry  feeble  ;  the 
skin  cold,  particularly  on  the  limbs.  From  the  1st  to  the  6th  of  De- 
cember, all  these  symptoms  continued  with  great  intensity  ;  the  di- 
arrhoea continued  to  be  abundant ;  vomiting  still  existed  ;  at  last  the 
child,  pale,  feeble,  and  excessively  wasted,  succumbed  on  the  eighth, 
after  vomiting  a  large  quantity  of  green  and  yellow  matters. 

Post  mortem  examination. — There  was  a  general  discoloration 
of  the  integuments,  and  some  violet-colored  sugillations  appeared  on 
the  back  and  nates.  The  base  of  the  tongue  exhibited  a  'violet  ec- 
chymosis  about  the  size  of  ten-sous  piece  ;  the  oesophagus  w^as  pale 
throughout  its  whole  length ;  the  stomach  exhibited  the  same  ap- 
pearance ;  but  besides  this,  four  superficial  excoriations,  three  lines 
in  length,  and  pale  like  the  rest  of  the  membrane,  were  found  near  the 
pylorus.  The  mucous  membrane  of  the  small  intestines  presented, 
throughout  its  whole  extent,  a  marked  discoloration ;  it  was  at  the 
same  time  so  friable,  that  on  scraping  it  very  slightly,  it  was  raised  in 
small  shreds  which  were  easily  reduced  to  a  soft  mass.  In  the  ileo- 
caecal  region  there  existed  several  follicular  patches,  which  partook 
of  the  paleness  of  the  rest  of  the  intestines,  and  besides  this,  there 
were  in  the  same  region  a  mottled  redness,  pale  at  the  edges,  and 
which  appeared  to  be  the  traces  of  the  color  of  the  intestinal  tube 
before  it  changed. 

The  liver  was  large,  and  filled  with  blood ;  the  gall-bladder 
very  much  distended  by  a  large  quantity  of  green  porraceous  bile  ; 
the  lungs  were  gorged  with  blood ;  the  foetal  openings  obliterated ; 
the  brain  very  much  injected. 

It  is  remarkable  that  the  large  abdominal  veins  in  this  child 
had  retained  much  of  the  blood,  while  the  mucous  membrane 
was  entirely  colorless.  Softening  of  the  digestive  mucous  mem- 
brane supervened  here  in  a  child  who  was  doubtless  affected 
prematurely  with  gastro-enteritis ;  and  this  gastro-enteritis  hav- 
ing suspended  the  digestive  functions,  produced  marasmus, 
paleness,  and  afterwards  a  softening  of  the  digestive  tube  from  a 
defect  of  alimentation.     If  this  softening  were  the  necessary  re- 


ON    THE    DISEASES    OP    INFANTS.  325 

suit  of  inflammation,  there  never  would  occur  softening  without 
inflammation  ;  yet  we  have  seen  the  contrary  of  this.  The  sub- 
ject of  the  following  case  was  in  a  condition  analogous  in  every 
respect  to  that  usually  occurring  in  the  marasmus  and  wasting 
of  a  child  badly  nourished,  and  of  which  we  have  already  spoken 
when  treating  of  intestinal  indigestion. 

CASE  LII. — Louise  Massan,  aged  one  month,  had  been  suckled 
at  the  Hospice  des  Enfans  Trouves  since  birth.  She  was  pale  and 
thin,  as  all  are  that  are  under  the  care  of  the  hospital  nurses.  She 
vomited  often,  and  was  affected  with  a  diarrhoea  of  green  matters, 
which  ceased  spontaneously  after  two  or  three  days.  This  child  en- 
tered the  infirmary  on  the  26th  of  February.  She  was  thin,  pale,  and 
very  quiet ;  the  skin  was  so  white  as  to  be  almost  transparent,  and 
the  small  blue  veins  could  be  distinctly  seen  on  various  parts  of  the 
body.  She  was  not  affected  with  fever,  respired  well,  and  cried  but 
little.     {Sweetened  rice-water,  milk  and  water.) 

This  child  remained  in  the  infirmary  until  the  1st  of  April,  without 
presenting  any  other  symptom  than  those  just  described ;  during 
this  time  she  became  affected  with  marasmus,  and  the  skin  assumed 
the  appearance  of  wax.  She  died  on  the  1st  of  April.  On  opening 
the  body,  the  abdomen  was  found  excessively  distended  with  gas,  and 
the  intestines  were  so  thin  and  transparent,  that  their  contents  could 
easily  be  seen  through  their  walls.  The  stomach,  small  and  great 
intestines,  exhibited,  through  their  whole  extent,  a  chlorotic  pale- 
ness, and  the  mucous  membrane  was  so  soft,  that  the  mere  touch  re- 
duced it  to  a  soft  mass,  resembling  mucus  more  than  a  membranous 
substance.  The  liver,  spleen,  lungs,  heart,  and  brain  were  healthy, 
and  all  these  organs  were  exsanguineous. 

This  infant  was  doubtless  reduced  to  this  state  of  marasmus 
and  extreme  feebleness  by  the  insufficient  and  improper  alimen- 
tation to  which  she  was  subjected,  the  effects  of  which  were  ma- 
terially aided  by  her  prolonged  continuance  in  the  infirmary, 
where  a  great  number  of  sick  children  were  assembled,  render- 
ing the  air  insalubrious.  The  softening  in  this  case  was  not  pre- 
ceded by  inflammation,  but  had  been  for  a  long  time  coming  on 
from  an  opposite  cause.  Sometimes  this  softening,  instead  of  be- 
ing general,  is  only  found  in  a  few  isolated  points  of  the  intesti- 


326  ON   THE    DISEASES    OP    INFANTS. 

nal  tube.  It  is  met  with  not  only  after  birth,  but  likewise  in 
children  who  die  during  birth,  as  I  have  often  had  occasion  to 
observe.  It  appears  always  to  follow  an  absence  of  the  blood  in 
the  mucous  tissue  ;  it  is  this  which  has  led  M.  Denis  to  consider 
it  as  a  sort  of  retiring  of  the  blood,  retrait  du  sang,  as  he  has 
termed  it.  But  here  the  absence  of  the  sanguineous  fluid  is  not 
the  immediate  cause  of  the  softening ;  it  is  itself,  like  the  pale- 
ness and  softening,  the  effect  of  a  default  of  alimentation  ;  be- 
sides, there  is  not,  properly  speaking,  a  retiring  of  blood ;  for 
whence  would  it  retire  ?  When  an  infant  dies  in  the  condition 
we' have  just  described,  all  its  organs  are  found  exsanguineous, 
particularly  the  external  integuments  ;  and  it  is  rather  to  be  at- 
tributed to  a  diminution,  alteration,  and  suspension  of  sanguifica- 
tion, the  disturbance  of  which  function  being  caused  either  by 
the  indigestible  drinks  taken,  or  by  the  unhealthy  air  respired  ; 
so  that  the  very  spring  of  life  is  insensibly  dried  up,  and  the  child 
perishes  from  debility  and  hunger.  The  white  softening  now 
under  consideration,  is,  therefore,  to  be  regarded  as  an  advanced 
stage  of  the  discoloration  of  the  intestines  pointed  out  in  the  his- 
tory of  intestinal  indigestion,  the  cause  of  which  has  its  origin  in 
the  insuflicient  and  improper  alimentation  to  which  an  infant  is 
exposed  in  hospitals.  This  softening  has  apparently  some  ana- 
logy to  that  which  is  both  generally  and  locally  developed  in  the 
intestinal  tube  of  persons  affected  with  phthisis,  upon  the  nature 
of  which  MM.  Louis  and  Andral  have  made  some  interesting  re- 
searches. 

Among  the  symptoms  indicating  this  sort  of  softening,  we  will 
particularly  point  out  the  general  discoloration  of  the  integu- 
ments, and  the  blanched  appearance  of  the  children  affected  with 
it,  the  skin  having  a  close  resemblance  to  that  of  a  chlorotic  girl. 
Other  symptoms,  such  as  diarrhoea,  tympanitis,  etc.,  being  com- 
mon to  other  intestinal  affections,  cannot  be  considered  as  of  any 
importance  in  the  diagnosis  of  this  disease. 

Softening  of  the  intestines  must  be  regarded  as  an  affection  al- 
together incurable  ;  an  entire  regeneration  of  the  mucous  mem 
brane  would  be  necessary,  which  is  an  impossibility.  The  treat- 
ment ought  then  to  be  previously  directed  to  an  attempt  to  reme- 
dy the  first  effects  of  the  want  of  alimentation,  and  in  having  re- 
course to  every  means  that  can  restore  the  impaired  condition  of 


ON    THE    DISEASES    OF    INFANTS.  327 

the  digestive  functions,  before  the  disorganization  of  the  mucous 
membrane  has  occurred. 

Art.  5.— An  examination  of  the  principal  Symptoms  of  the  Diseases  of  the  Digestive 

Canal. 

All  the  lesions  to  which  the  digestive  apparatus  is  liable,  have 
been  considered;  and  I  will  now  endeavor  to  give  an  account  of 
the  symptoms  proper  to  each,  and  such  as  may  be  recognised 
during  life.  Authors,  generally,  who  have  written  on  the  dis- 
eases of  children,  have  been  more  systematic,  and  have  taken  the 
symptoms,  or  the  groups  of  symptoms,  as  a  foundation  of  their 
divisions,  without  regard  to  the  anatomical  lesions.  In  a  rapid 
examination,  I  propose  to  estimate  the  value  of  these  symptoms, 
together  with  their  relation  to  the  anatomical  lesions  of  which 
they  are  the  effect. 

Vomiting. — Vomiting  may  occur  from  several  causes  ;  such 
as  gastric  or  intestinal  indigestion,  produced  probably  by  the  bad 
qualities  of  the  milk,  oesophagitis,  gastritis,  enteritis,  particularly 
when  seated  in  the  ileo-csBcal  region,  interruption  of  the  course 
of  foecal  matters  from  invagination  or  spasm  of  the  mtestines,  and 
lastly,  from  softening  of  the  mucous  membrane.  In  considering  this 
symptom,  the  cause  producing  it  should  always  be  taken  into  ac- 
count, and  the  facts  properly  studied.  It  is  impossible  to  draw 
any  practical  inference  from  this  symptom  taken  separately ;  but 
to  give  its  clinical  history  it  will  be  necessary  to  examine  all  the 
affections  of  the  digestive  tube,  for  vomiting,  as  we  have  seen,  is 
common  to  all  of  them.  This  manner  of  considering  and  esti- 
mating the  vomiting  of  infants  at  the  breast,  appears  to  me  much 
more  philosophical  than  to  imagine  and  establish,  d  priori,  the 
causes  of  this  morbid  phenomenon,  as  has  been  done  by  a  num- 
ber of  authors. 

Diarrhoea. — Diarrhea  is  not  a  constant  sign  of  enteritis  ;  it 
may  be  produced  by  intestinal  indigestion,  by  a  state  of  irritation, 
or  an  increase  of  the  secretion  of  the  follicular  apparatus,  by  co- 
litis, or  enteritis.  The  discharges  vary  in  color  and  consistence  ; 
a  yellow,  frothy,  and  fluid  diarrhoea  is  very  often  accompanied 
with  inflammation  ;  a  white  and  mucous  diarrhoea  is  often  pro- 
duced by  an  augmentation  of  the  secretion  of  the  muciparous  fol- 


32S  ON   THE    DISEASES   OF    INFANTS. 

licles ;  when  mixed  with  green  flakes,  it  olten  exists  without  in- 
flammation. 

Redness  surrounding  the  anus. — This  exists  in  almost  every 
case  of  diarrhoea,  whether  with  or  without  inflammation. 

Tension  of  the  abdomen. — This  affection  is  usually  observed 
in  enteritis,  and  is  then  accompanied  with  abdominal  pain.  The 
distension  of  the  intestines  by  gas,  when  it  arises  from  spasm  of 
the  intestines,  produces  the  same  phenomenon  ;  but  it  is  inter- 
mittent, and  the  pain  ceases  when  the  gas  escapes,  while  it  con- 
tinues without  intermission  when  arising  from  inflammation. 
Tension  of  the  abdomen,  when  there  is  softening  of  the  mucous 
membrane,  generally  exists  without  pain,  and  is  accompanied 
with  a  state  of  general  wasting  and  paleness. 

Colic. — Colic  may  be  spasmodic,  or  the  result  of  inflamma- 
tion, invagination,  imperforation  of  the  anus,  distension  from  gas 
during  inflammation,  or  when  this  pathological  condition  does 
not  exist,  it  may  arise  from  indigested  aliments  remaining  for 
some  time  in  the  intestines.  This  is  what  authors  have  de- 
scribed under  the  name  of  flatulence.* 

Cholera. — Cholera  is  not  generally  noticed  in  our  climate  ;  it 
is  a  disease  peculiar  to  infants  in  the  United  States  ;  and  as  I 
have  not  observed  any  thing  analogous  to  this  affection,  I  must 
be  indebted  to  Dr.  Dewees  for  the  principal  details  of  the  symp- 
toms.t 

This  disease  begins  with  vomiting,  copious  diarrhoea,  great 

cerebral  affection,  and  an  intense  thirst.  The  pulse  is  small, 
quick,  and  corded.  The  evacuations  from  the  bowels  vary  con- 
siderably ;  they  are  sometimes  yellow,  brown,  and  watery ;  at 
other  times,  more  thick  and  tenacious  ;  they  are  sometimes  mix- 
ed with  blood,  and  almost  always  yield  an  odor  exceedingly  of- 
fensive. The  irritability  of  the  alimentary  canal  is  sometimes 
so  great  that  the  ingesta  rapidly  pass  off  as  in  lientery.  The 
skin  of  the  forehead  is  tight ;  the  eyes  are  sunk ;  the  nose  is 
sharp,  and  the  lips  are  shrivelled ;  the  belly  is  tumefied  ;  the  feet 
are  OBdematous,  and  aphthae  appear.  This  condition  may  con- 
tinue for  five  or  six  weeks,  but  as  death  approaches,  a  gradual 

♦  See  Appendix,  page  578. 

+  A  Treatise  on  the  physical  and  medical  treatment  of  children^  by  W.  P.  DetoeeSj 
M.  D.,  2d  edition.    Philadelpliia,  1826,  p.  395. 


ON    THE    DISEASES    OF    INFANTS.  329 

aggravation  of  symptoms  take  place.  Sometimes  there  are  seen 
on  the  chest  an  immensity  of  watery  vesicles.  Children  are 
sometimes  seen  thrusting  their  fingers  into  the  back  part  of  the 
mouth,  as  if  desirous  of  removing  something.  The  popular 
opinion  is,  that  there  is  a  worm  irritating  the  back  part  of  the 
throat. 

Dissections  show  the  following  anatomical  lesions  :  the  brain 
is  generally  in  a  state  of  congestion  )  the  thoracic  Viscera  are 
rarely  affected ;  but  it  is  on  the  contents  of  the  abdomen  that  it 
mainly  expends  its  force  j  the  stomach  and  small  intestines  ex- 
hibit dark  livid  spots  dispersed  over  the  mucous  membrane,  par- 
ticularly near  the  pylorus.  In  many  parts  there  is  an  alteration 
of  the  structure,  by  the  thickening  of  their  coats  ;  so  much  so, 
that  the  calibre  of  the  tube  is  reduced  considerably.  The  large 
intestines  are  seldom  or  never. involved  in  the  mischief,  excepting 
where  the  disease  assumes  a  dysenteric  form.  The  liver  is  of  a 
large  size,  and  filled  with  blood,  and  the  gall-bladder  is  filled  with 
a  dark  green  bile.  The  other  viscera  of  the  abdomen  are  usually 
healthy. 

It  is  evident  that  all  these  symptoms  described  by  Dr.  Dewees, 
are  those  of  a  violent  gastro-enteritis,  complicated  with  hemorr- 
hage, of  which  affection  we  have  given  several  examples,  (v. 
cases  xLi.  and  l.,)  and  although  cholera  infantum  is  rare  in  our 
country,  yet  there  sometimes  exist  instances  of  it,  particularly  in 
our  hospitals,  where  children  are  brought  that  are  born  in  the 
midst  of  the  most  frightful  misery,  scarcely  protected  by  a  iew 
rags  from  the  inclemency  of  the  atmosphere.  Dr.  Dewees  has 
detailed  the  treatment  of  this  disease  at  length ;  and  in  truth, 
nothing,  in  our  opinion,  can  be  more  irritating  than  his  method  ; 
he  attaches  too  much  importance  to  the  treatment  of  the  prostra- 
tion and  the  symptoms  of  putridity.  He  also  advises  the  treat- 
ment to  be  commenced  with  vomiting,  and  afterwards  a  tea- 
spoonful  of  strong  coffee,  without  sugar  or  milk,  every  fifteen 
minutes,  to  be  given  especially  to  very  young  children.  We 
have,  says  he,  since  we  first  tried  it,  seen  it  act  like  a  charm. 
He  adds,  "If  the  stomach  has  not  been  tranquillized  by  the  cof- 
fee, we  immediately  commence  with  minute  doses  of  calomel, 
but  never  combined  with  opium.  The  following  is  the  form 
and  average  dose  we  use : 

42 


330  ON   THE    DISEASES    OP    INFANTS. 

^  Calom.  ppt.  gr.  iij. 
Sacch.  all.  gr.  vi. 
M  divid.  in  pulv.  xij. 

This  should  be  given  until  the  stools  become  less  abundant,  and 
less  green."  When  the  evacuations  of  the  bowels  are  moderated, 
injections  with  laudanum,  proportionate  to  the  age  of  the  child, 
should  be  administered ;  to  this  is  added  the  use  of  rhubarb  and 
absorbent  powders,  the  application  of  blisters  to  the  limbs,  and 
dry  frictions  with  flannel,  etc.  Such  tonic  treatment  might  per- 
haps succeed  in  a  climate  different  from  ours ;  but  when  the  na- 
ture of  the  anatomical  lesions  which  produce  the  symptoms  con- 
stituting cholera  infantum,  are  considered,  we  ought  certainly  to 
hesitate  about  employing  it ;  and  it  must  be  acknowledged  that 
it  has  not  been  very  successful  in  America,  since  the  disease  still 
continues  to  make  frightful  ravages  in  that  country.  Indeed, 
Dr.  Parrish  commences  an  essay,  which  he  published  in  1826, 
with  these  remarkable  words  :  "  The  great  mortality  of  cholera 
infantum  renders  it  one  of  the  most  interesting  diseases  which 
comes  under  the  notice  of  the  physician.  Its  ravages  among  the 
infant  population  of  our  large  cities,  are  well  known  and  too 
strongly  felt  to  require  any  comment.  No  disease  contributes  so 
large  to  swell  our  bills  of  mortality  during  its  prevalence  ;  and 
were  it  not  restricted  to  the  summer  season,  it  would  prove  a 
greater  scourge  to  the  community  than  consumption  itself."* 

Considering  the  nature  of  this  disease,  if  the  American  physi- 
cians were  to  adopt  a  system  of  treatment  less  inflammatory,  they 
might  perhaps  have  less  reason  to  lament  the  ravages  of  this 
species  of  gastro-enteritis. 

Dr.  Dewees  advises  the  removal  of  the  child  from  the  infected 
atmosphere  to  the  country  as  a  preventive,  and  to  this  precau- 
tion Dr.  Rush  recommends  nourishing  the  child  with  milk,  to 
cover  the  skin  with  flannel,  and  to  avoid  the  use  of  fruits,  being 
careful,  at  the  same  time,  to  give  as  aliment  nothing  but  farina- 
ceous substances,  as  rice,  arrowroot,  biscuit,  etc.,  and  some  time 
after  the  appearance  of  the  teeth,  to  give  a  little  animal  food  to 
strengthen  the  digestive  organs. 

♦  Remarks  on  the  prophylactic  treatment  of  cholera  infantum.  North  Amencan 
Medical  and  Surgical  Journal,  July,  1826. 


ON    THE    DISEASES    OF    INFANTS.  331 

Dr.  Pjirrishj  in  the  memoir  cited,  also  insists  much  on  the  ne- 
cessity of  a  tonic  and  stimulant  diet,  as  a  prophylactic  of  cholera. 
In  this  manner  he  was  enabled  to  raise  the  child  of  a  lady  who 
had  previously  lost  eight  children  from  this  disease.  This  child, 
from  its  earliest  infancy,  was  accustomed  to  the  most  stimulating 
food,  and  several  spoonfuls  of  ginger  tea  were  daily  given  to  it, 
followed  afterwards  by  the  juice  of  meat.  During  the  summer, 
the  nurse  used  the  most  nourishing  aliment,  taking  the  precau- 
tion not  to  eat  either  fruit  or  vegetables.  The  second  year,  va- 
rious preparations  of  animal  food,  beef  tea,  port  wine,  etc.,  were 
adopted  as  diet  for  the  child,  until  it  had  passed  the  period  of 
dentition,  without  experiencing  any  symptom  of  disease,  the  very 
idea  of  which  was  extremely  distressing  to  the  mother. 

I  know  of  no  practitioner  in  France  that  would  be  tempted 
under  similar  circumstances  to  adopt  the  same  method  of  ali- 
mentation for  infants,  or  to  approve  of  its  use.* 

Symptoms  of  reaction  of  intestinal  diseases. — Avery  remark- 
able fact,  and  one  to  which  we  have  frequently  alluded  in  the 
view  we  have  taken  of  the  diseases  of  the  digestive  apparatus,  is, 
that  generally  in  young  infants  there  do  not  exist  so  well-marked 
symptoms  of  reaction  as  in  adults.  The  heat  of  the  skin  alone 
is  augmented,  and  we  have  seen  a  great  number  sink  under  the 
most  serious  lesions,  without  exhibiting  any  fever,  the  feebleness 
of  the  pulse  being  rather  a  symptom  of  reaction  than  the  accele- 
ration of  the  circulation.  Thus  then,  age  exerts  an  important 
modification  on  the  affections  of  the  digestive  tube. 

1  shall  finish  this  long  chapter  with  an  observation  worthy  of 
the  attention  of  all  pathological  physiologists  ;  it  is,  that  the  di- 
gestive apparatus,  possessing  at  the  period  of  birth  an  advanced 
state  of  formation  and  development,  and  fulfilling  functions  of 
fi^reat  activity,  becomes  at  the  same  time  the  seat  of  a  great  num- 
ber of  diseases  in  young  infants  ;  it  is  indeed  by  derangement  of 
the  digestive  tube  that  great  numbers  of  them  perish,  and  it  is 
by  means  of  this,  that  their  general  health  becomes  affected,  and 
the  proper  development  of  their  constitution  is  prevented. 

I  have  not  spoken  of  intestinal  worms  ;  children  at  the  breast 
being:  seldom  or  never  affected  with  them. 

*  See  Appendix,  page  580. 


332  ON   THE    DISEASES    OF    INFANTS. 

CHAPTER    III, 

DISEASES  OF  THE  APPENDAGES  OF  THE  INTESTINAL  CANAL. 


Section  I. 

DEVELOPEMENT    AND     CONGENITAL     MALFORMATIONS     OF     THE 

LIVER. 

The  liver  begins  to  be  developed  at  a  very  early  period ; 
Walter  has  proved  that  in  the  embryo  of  three  weeks,  its  weight 
is  half  that  of  the  rest  of  the  body ;  and  in  the  fostus  at  the  full 
term,  with  reference  to  the  body,  it  is  as  one  to  eighteen  or  twen- 
ty.* In  the  infant  at  birth,  it  fills  almost  the  third  of  the  abdo- 
minal cavity,  for  it  descends  even  to  the  crest  of  the  ilium. 
During  the  intra-uterine  life,  therefore,  the  liver  exhibits  very 
early  a  development  sufficient  to  allow  of  its  being  considered  as 
one  of  the  most  important  abdominal  organs ;  it  exercises  indeed 
some  essential  functions  with  respect  to  the  foetal  circulation  ;  and 
perhaps  also  with  respect  to  nutrition,  for  its  secretion  may  in 
some  sort  concur  in  the  alimentation  of  the  foetus.  I  shall  not 
stop  to  examine  this  idea,  which  may  as  yet  be  regarded  only  as 
a  conjecture. 

Congeriital  malformations. — The  liver  is  only  completely 
absent  in  cases  of  complete  acephalia ;  it  does  not  always  occupy 
in  the  infant  at  birth  the  place  which  nature  generally  assigns 
to  it ;  and  it  may  be  found  on  the  outside  of  the  abdomen,  in  cases 
of  an  imperfection  of  the  walls  of  the  abdomen,  and  even  in  the 
thoracic  cavity,  when  a  portion  of  the  diaphragm  is  wanting. 
It  also  exhibits  deep  divisions,  and  sometimes  alterations  of  form 
of  little  importance. 

Absence  of  the  gall  bladder,  when  the  ducts  exist,  is  possible, 
without  being  productive  of  any  accident ;  but  I  do  not  know 
that  children  are  ever  born  with  a  complete  absence  of  the 
biliary  ducts. 

♦  Meckel,  General  Anatomy. 


ON   THE    DISEASES    OP    INFANTS.  333 

In  a  word,  children  at  birth  are  rarely  affected  with  malforma- 
tion of  the  liver,  which,  like  the  greater  number  of  those  hereto- 
fore considered,  alter  the  health  or  compromise  the  life  of  a  new- 
born child. 

Section  II. 

DISEASES    OF    THE    LIVER. 

English  physicians  attach  the  greatest  importance  to  diseases 
of  the  liver  in  children,  as  they  do  also  in  adults.  Most  of  the 
disorders  of  digestion  are  attributed  by  them  to  a  derangement  of 
the  functions  of  this  organ  ;  they  attribute  many  diseases  to  the. 
qualities  of  the  bile  that  the  liver  pours  into  the  intestines.  In 
order  to  obtain  fixed  data  upon  this  subject,  I  have  examined 
the  liver  in  a  number  of  infants  with  great  care,  and  considered 
especially  the  physical  qualities  of  the  bile,  and  the  symptoms 
which  they  had  presented  during  life,  and  I  have  never  seen 
any  thing  in  these  lesions  and  symptoms  which  could  explain 
the  ideas  of  the  English  pathologists  in  reference  to  the  influence 
which  affections  of  the  liver  might  exercise  upon  the  health  of 
the  child.  Before  exhibiting  the  general  results  of  these  re- 
searches, I  will  say  a  few  words  on  the  diseases  of  the  liver  de- 
veloped before  birth. 

Congenital  diseases  of  the  liver. — This  organ  is  often  the  seat 
of  sanguineous  congestion  during  intra-uterine  life.  It  is  fre- 
quently of  a  dark  red  color.  In  two  instances  I  found  its  tissue 
considerably  softened,  and  diffusing  an  odor  of  sulphuretted 
hydrogen :  in  both  these  cases,  the  children  had  arrived  at  the 
full  term,  possessed  a  good  constitution,  and  externally  exhibited 
no  evidence  of  wasting.  I  once  found  in  the  liver  of  a  newly 
born  child,  a  number  of  small  tuberculous  granulations ;  they 
also  existed  in  the  spleen  and  lungs.  They  will  be  considered 
when  we  come  to  treat  of  pulmonary  tubercles.  As  to  the  quan- 
tity and  physical  qualities  of  the  bile  in  infants,  nothing  is  more 
variable,  and  I  am  unable  to  furnish  with  regard  to  it  any  gene- 
ral and  fixed  doctrine.  In  short,  passive  congestions  of  the  liver 
are  the  most  frequent  lesions  of  this  organ  in  young  infants;  a 
condition  easily  understood  since  the  hepatic  circulation  is  under 


334  ON   THE    DISEASES    OF    INFANTS. 

the  direct  dependence  of  the  general  circulation,  and  would  con- 
sequently experience  promptly  the  disorders  which  supervene  in 
the  functions  of  the  circulating  apparatus. 

Diseases  developed  after  birth. — In  order  properly  to  appre- 
ciate the  changes  which  take  place  in  the  liver,  we  must  first 
make  known  its  various  aspects  in  a  state  of  health.  In  nearly 
all  newly  born  children,  the  liver  is  of  a  deep  reddish  brown, 
and  is  almost  always  gorged  with  blood,  which  issues  in  nume- 
rous drops  whenever  the  organ  is  cut,  and  is  generally  black 
and  fluid;  the  gall-bladder  long,  and  of  little  volume,  is  filled 
with  viscid  bile  of  a  porraceous  green.  In  proportion  as  the 
child  advances  in  age,  the  sanguineous  engorgement  becomes 
less,  and  the  bile  somewhat  more  abundant,  and  the  gall-bladder 
more  distended. 

The  consistence  of  the  tissue  of  the  liver  is  such,  that  it  can 
always  be  cut  smoothly,  and  does  not  tear  except  upon  the  appli- 
cation of  considerable  force. 

Congestion. — The  slightest  impediment  to  the  circulation 
gives  rise  to  passive  congestions  of  the  liver.  These  congestions 
are  very  common  in  infants  at  birth,  and  vary  considerably  with 
respect  to  the  quantity  of  blood  accumulated  in  the  tissue  of  the 
organ.  It  is  sometimes  also  found  there  in  so  great  quantity  as 
to  produce  a  sort  of  sanguineous  exudation  on  the  surface  of  the 
liver,  particularly  on  the  convex  portion,  which  is  in  this  case 
covered  with  a  layer  of  blood  over  its  whole  extent.  I  have  also 
seen  in  several  infants,  an  effusion  of  blood  in  the  abdomen,  the 
result  of  this  turgescence.  The  symptoms  presented  by  children 
aflfected  with  hepatic  congestion,  are  so  obscure  as  to  make  it 
difficult  to  detect  the  existence  the  disease ;  they  are  the  same 
as  those  of  pulmonary  congestion.  In  asphyxia  of  new-born 
children,  for  instance,  there  is  nothing  more  common  than  to 
find  the  liver  considerably  gorged  with  fluid  black  blood ;  the 
large  abdominal  vessels  and  the  whole  of  the  circulatory  appara- 
tus are  in  the  same  condition.  Hepatic  congestion  then  arises 
from  a  kind  of  reflux  of  the  sanguineous  fluid  towards  the  abdo- 
minal organs,  among  which  the  liver,  by  reason  of  its  great  vas- 
cularity, is  peculiarly  disposed  to  injection  and  engorgement. 

The  congestions  of  the  liver  would  appear  sometimes  to  change 
the  nature  of  its  secretion :  in  some  infants,  where  the  liver 


ON   THE    DISEASES    OP    INFANTS.  335 

was  very  much  injected,  I  have  found  the  gall-bladder  distended 
and  filled  with  thick  bile,  of  a  black  green,  and  even  bloody.  I 
once  saw  in  a  young  infant  in  the  place  of  bile,  black  ropy 
blood.  It  might  be  supposed  that  in  this  child,  the  liver,  changed 
in  its  texture,  could  not  produce  in  the  blood  which  it  receives 
for  the  biliary  secretion,  the  vital  or  physiological  modification, 
which  this  fluid  must  undergo  to  form  bile. 

The  treatment  of  hepatic  congestions  ought  to  be  the  same  as 
that  of  intestinal  or  thoracic  congestions,  since  this  condition  oc- 
curs in  all  three  of  them  at  the  same  time,  all  apparently  being 
closely  connected  by  the  various  branches  of  the  same  circulatory 
trunk. 

InJlamw,ations. — I  know  of  no  organ  the  inflammation  of 
which  is  so  difficult  to  prove,  as  that  of  the  liver  ;  its  alterations 
of  color  and  texture  are  so  numerous  and  so  variable,  that  it  is 
extremely  difficult  to  know  to  what  cause  to  refer  these  changes  ; 
and,  without  alluding  here  to  the  innumerable  changes  of  color 
in  the  liver  of  an  adult,  I  might  mention  a  great  variety  of  color 
which  the  liver  in  a  young  infant  presents.  Possessing  no  posi- 
tive facts  in  reference  to  the  anatomical  characters  and  the  symp- 
toms of  hepatitis  in  infants  at  the  breast,  I  shall  refrain  from 
being  a  barren  copyist  of  authors ;  and,  in  the  absence  of  data 
necessary  to  give  a  correct  history  of  inflammation  of  the  liver, 
I  shall  only  record  the  general  results  of  my  researches  upon  the 
various  aspects  of  the  liver,  considered  in  its  relation  to  the  quan- 
tity and  quality  of  the  bile,  and  the  symptoms  which  the  diges- 
tive apparatus  presents. 

Examination  of  the  different  states  of  the  liver ^  considered  in 
their  relation  to  the  qualities  of  the  bile. — These  researches  were 
made  upon  fifty  children,  of  both  sexes,  aged  from  one  day  to 
six  and  eight  months. 

In  twelve  of  these,  where  the  liver  exhibited  all  the  apparent 
characters  of  a  state  of  health,  without  being  injected  or  infiltra- 
ted with  more  blood  than  ordinary,  I  found  the  bile  discolored 
and  slightly  viscid  in  two  ;  abundant,  without  color,  and  clear 
like  serum  in  three  ;  of  a  beautiful  green,  and  in  small  quantity, 
in  one  ;  black  and  very  abundant  in  two  ;  small  in  quantity  and 
of  a  clear  yellow  in  two ;  of  a  yellowish  green  and  very  viscid 
in  two. 


336  ON    THE    DISEASES    OF    INFANTS. 

From  this  it  is  already  seen  that,  however  healthy  the  liver 
may  appear  to  be,  the  color  and  consistence  of  the  bile  are 
extremely  variable.     But  let  us  pursue  our  analysis. 

The  liver  was  very  much  gorged  with  blood  in  twenty-eight 
children ;  the  bile  was  of  a  deep  green  and  of  the  usual  quanti- 
ty in  ten  of  these  ;  in  eight  others  it  was  of  a  very  pale  green  ; 
in  two  it  was  mixed  with  blood  ;  it  was  yellow,  thick,  and  con- 
crete in  three ;  in  small  quantity  and  of  an  ochery  color  in  four ; 
and  in  one,  it  was  replaced  by  a  white  ropy  fluid,  like  mucus. 

Thus  it  appears  that  the  sanguineous  congestion  of  the  liver 
does  not  produce  any  alteration  of  the  secretion  always  identical, 
at  least,  in  appearance  ;  since  we  have  here  seen  that  the  quan- 
tity and  quality  of  the  bile  varies  greatly  in  infants  where  the 
liver  is  found  in  the  same  pathological  state.  There  remain  ten 
infants  to  examine  :  in  these  the  liver  exhibited  several  shades 
of  color,  and  the  character  of  the  bile  was  not  less  variable.  In 
three,  the  organ  was  exsanguineous  and  very  pale  ;  the  bile  was 
very  pale  in  one,  of  a  very  deep  color  in  the  second ;  of  a  black- 
ish green,  mixed  with  blood,  in  the  third.  Here,  and  this  is  very 
remarkable,  we  find  the  bile  of  a  deep  green  in  an  infant  where 
the  liver  was  exsanguined,  whilst  in  those  where  the  liver  was 
gorged  with  blood,  the  bile,  on  the  contrary,  was  clear  and  color- 
less. 

In  the  fourth  of  the  ten  children  now  under  consideration,  the 
liver  was  friable,  and  had  a  granulated  appearance  when  torn, 
and  its  substance,  which  appeared  infiltrated  with  a  yellow  sero- 
sity,  was  of  the  color  of  ochre.  The  bile,  which  was  very  abun- 
dant, was  green  and  slightly  viscid.  In  the  fifth,  the  liver  was 
of  a  rose  color ;  the  bile  was  yellow  and  scanty.  In  the  sixth 
and  seventh,  the  liver  was  very  large  and  pale ;  the  bile  in  one 
was  colorless,  and  in  the  other  of  a  yellowish  green.  In  the 
eighth,  the  liver  was  grayish  externally ;  this  color  only  existed 
at  the  surface  ;  for,  upon  cutting  into  the  substance,  it  was  found 
of  a  deep  brownish  red  ;  it  was  also  very  friable,  and  could  be 
torn  with  the  greatest  ease.  The  bile  was  green  and  ropy ;  the 
gall-bladder  was  covered  on  the  interior  surface  with  very  thick 
mucus.  In  the  ninth,  the  liver,  externally,  was  of  a  slate  color, 
and  green  internally  ;  it  was  firm,  and  left  a  smooth  surface  on 
cutting  it ;  the  bile  was  in  its  natural  condition.     And  in  the 


ON  THE   DISEASES   OP    INFANTS.  337 

tenth,  the  Hver  was  reduced  to  a  soft  reddish  mass,  and  diffused, 
when  crushed,  an  odor  of  sulphuretted  hydrogen.  The  bile  was 
very  abundant  and  of  a  deep  green  ;  it  contained  a  great  quan- 
tity of  blood,  which,  instead  of  being  mixed  with  the  bile,  was 
separated  into  distinct  clots  and  filaments. 

From  these  researches  it  results,  that  the  appearances  of  the 
Hver  are  very  variable,  and  of  the  bile  not  the  less  so  ;  and  that 
it  is  really  impossible  to  establish  between  the  state  of  the  bile 
still  retained  in  the  reservoirs,  and  the  normal  and  pathological 
state  of  the  liver,  any  connection  that  may  lead  to  general  conclu- 
sions. The  qualities  of  the  bile  may  vary,  from  a  number  of 
modifications  occurring  in  the  secretory  process  of  our  organs  : 
modifications  which  we  cannot  understand  while  the  veil  which 
conceals  the  manner  of  the  process  from  our  senses  still  remains. 
Thus,  then,  in  ascending  to  the  causes  and  nature  of  the  dis- 
eases of  the  liver  in  young  infants,  I  am  obliged  to  acknowledge 
my  ignorance  and  incapacity  ;  however,  I  here  find  an  opportu- 
nity of  pointing  out  a  vacuum  to  be  supplied,  and  this  is  a  re- 
compense for  my  trouble,  for  it  is  still  serving  the  cause  of  'sci- 
ence to  exhibit  error,  and  to  learn  how  to  shun  it  when  disco- 
vered. 

I  have  not  limited  these  preliminary  researches  to  the  consider- 
ation of  the  nature  and  causes  of  diseases  of  the  liver,  but  have 
undertaken  other  analytical  observations  ;  to  ascertain  how  far 
authors  are  correct  in  attributing  to  affections  of  the  liver,  diar- 
rhoea, consisting  either  of  green  or  yellow  evacuations,  with 
which  infants  are  so  often  affected. 

Examinations  of  the  conditions  of  the  liver  and  qualities  of 
the  bile)  with  reference  to  intestinal  discharges. — Of  forty-eight 
children  that  died  of  enteritis,  or  gastro-enteritis,  twenty  had  di- 
arrhoea of  very  abundant  yellow  foeces,  and  twenty-six  diarrhoea 
equally  abundant  of  very  green  foeces.  The  following  exhibits 
the  condition  of  the  liver  and  bile  in  these  infants  :  in  fifteen,  the 
liver  was  scarcely  injected ;  and  in  these  fifteen  cases,  the  bile  was 
small  in  quantity,  and  very  clear  in  four  individuals  ;  it  was  of 
a  deep  green,  of  the  consistence  of  pitch,  and  very  abundant,  in 
three  ;  and  in  the  remainder  presented  nothing  remarkable.  In 
twenty-five,  the  liver  was  gorged  with  blood,  as  is  often  observed 
to  be  the  case  at  this  period  of  life ;  the  bile  in  each  of  them  ex- 

43 


338  ON   THE    DISEASES    OP    INFANTS. 

hibiting  different  characters ;  it  varied  from  a  pale  yellow  to  a 
deep  green ;  in  one  of  them,  there  existed  a  large  quantity  of 
black  blood  in  the  gall-bladder,  instead  of  bile. 

With  respect  to  the  eight  children  completing  the  number  of 
those  on  whom  my  researches  were  directed,  the  liver  exhibited 
shades  of  yellow,  green,  brown,  and  slate  color ;  the  bile  was 
fluid  and  clear  in  some,  while  it  was  thick  and  green  in  others. 

Thus  it  appears  that  in  the  forty-eight  children  to  whom  I  di- 
rected my  attention,  affected  with  diarrhoea  of  yellow  or  green 
matters,  the  liver  exhibited  very  different  appearances ;  some- 
times it  was  healthy,  often  injected,  and  again  it  presented  certain 
anatomical  characters  which  the  state  of  our  knowledge  does 
not  permit  us  to  refer  to  any  class  of  well-ascertained  diseases. 
What  inference  is  to  be  drawn  from  these  facts  ?  and  what  theo- 
ry is  to  be  established  on  so  uncertain  a  foundation  ?  Ought  we, 
after  the  example  of  most  of  the  English  pathologists,  to  attri- 
bute gratuitously  to  the  liver  the  derangements  of  the  digestive 
functions  ?  Ought  these  yellow  and  green  evacuations  to  be 
regarded  as  an  alteration  of  the  biliary  secretion  ?  I  leave  it  to 
other  authors  to  answer  these  questions,  when  ulterior  researches 
shall  throw  more  light  on  this  subject;  as  for  myself,  I  will  re- 
nounce my  opinions  only  when  convinced  of  their  error, — still 
believing  that  the  yellow  and  green  dejections,  whatever  may  be 
the  cause  of  their  color,  are  more  probably  a  symptom  of  enteri- 
tis, an  affection  which  must  be  removed  before  the  diarrhoea, 
which  is  only  its  effect,  can  be  cured. 

Such,  however,  is  not  the  opinion  of  Dr.  Dewees,  when  he 
says,  in  his  work  under  the  article  Diarrhoea,  "  In  bilious  diar- 
rhoea, the  foeces  are  loose,  copious,  and  of  a  bright  yellow  or 
green ;  and  the  bowels  are  stimulated  to  inordinate  action,  by 
an  overcharge  of  bile,  either  vitiated  or  not.  This  complaint  is 
very  frequent  among  our  children  during  the  heat  of  our  sum- 
mers, or  as  the  fall  approaches.  The  influence  of  the  hot  sun 
upon  the  actions  of  the  liver,  is  well  known  to  every  body ;  it  is 
familiar  to  common  observation,  that  after  a  spell  of  very  warm 
weather,  even  the  healthy  evacuations  of  an  adult  give  evidence 
of  its  rapid  formation,  and  sometimes  of  its  abundant  absorption. 
Thus  the  fosces  are  observed  to  be  loaded  with  bile ;  and  the 
urine  to  be  deeply  tinged  with  it ;  and  when  the  complaint  of 


ON   THE    DISEASES    OF    INFANTS.  339 

which  we  are  treating  seizes  upon  children,  it  is  called  the  « sum- 
mer complamt.' " 

Dr.  Dewees  observes,  that  no  period  of  infancy  is  free  from 
attacks  of  this  kind,  and  he  has  even  seen  extensive  bilious  eva- 
cuations from  children  of  ten  days  old. 

The  American  physicians,  therefore,  regarding  the  yellow 
diarrhosa  that  affects  children  during  the  summer  as  an  indica- 
tion of  an  afflux  of  irritating  bile  into  the  intestines,  advise,  in 
the  first  place,  to  evacuate  the  bowels,  using  the  remedy  for  that 
purpose  which  exerts  a  special  action  over  the  functions  of  the 
liver ;  such  as  calomel,  given  in  small  and  repeated  doses.  Dr. 
Dewees  has  recourse  to  laudanum  to  tranquillize  the  intestinal 
irritation  during  the  night :  he  gives  half  a  drop  for  a  child 
under  ten  days  ;  a  drop  for  one  from  that  period  to  the  end  of  the 
month  ;  a  drop  and  a  half  or  two  drops  for  one  from  that  period 
to  three  months ;  three  drops  from  this  time  to  nine  months ; 
four  drops  from  nine  months  to  eighteen.  If  fever  attend  the 
diarrhoea,  he  advises  the  use  of  the  warm  bath,  and  tartrite  of 
antimony,  which  he  administers  in  doses  from  the  tenth  to  the 
twentieth  or  twenty-fourth  part  of  a  grain.  Mr.  Barnes  advises 
besides  this,  nourishing  the  infant  with  beef  tea,  arrowroot,  and 
white  wine  whey.* 

Thus  then  while  the  examinations  of  the  bodies  of  those  who 
die  of  yellow  or  green  diarrhoea  demonstrate,  in  almost  every 
instance,  the  existence  of  enteritis,  the  American  physicians, 
without  taking  this  state  of  the  alimentary  canal  into  considera- 
tion, advise  emetics,  purgatives,  and  stimulants.  Perhaps  the 
great  ravages  of  inflammatory  diseases,  in  general,  in  those  cli- 
mates, may  in  part  be  attributed  to  the  method  of  treatment. 
Why  not  endeavor  to  ascertain  whether  there  really  exists  an 
afilux  of  bile  in  the  intestines  in  this  disease  ?  And  why  not 
attempt  to  show  by  anatomical  researches,  that  the  liver,  under 
the  influence  of  heat,  is  irritated,  and  ceases  to  discharge  its 
normal  functions ;  instead  of  advancing,  without  motive  and 
without  evident  facts,  the  opinion  that  the  bile  neutralizes  the 
acids  formed  in  the  stomach,  and  that  when  these  acids  are  very 
abundant,  and  mix  with  the  bile  in  such  a  manner  as  not  to  be 
neutralized,  a  green  color  is  thereby  imparted  to  the  alvine  eva- 

♦  Dewees,  loc.  cit.  p.  364. 


340  ON   THE    DISEASES    OF    INFANTS. 

cuations  ?  A  great  number  of  effects  are  attributed  to  this  acid, 
which  is  considered  a  sort  of  poison  that  ought  to  be  speedily- 
removed  from  the  aUmentary  canal.* 

These  ideas,  transmitted  from  period  to  period,  with  a  respect 
for  which  it  is  difficult  to  account,  except  by  referring  it  to  the 
blindness  with  which  men  sometimes  love  to  retain  their  preju- 
dices, cannot  be  sustained  by  the  analytical  examination  of  ana- 
tomical facts,  and  will,  with  other  medical  errors,  fall  into  obli- 
vion. If,  in  overthrowing  them,  we  are  unable  to  place  in  their 
stead  other  theories,  it  is  of  little  importance,  for  doubt  and  un- 
certainty are  still  better  than  error ;  for  instead  of  satisfying  us 
with  easy  explanations,  they  will  be  continually  harassing  us 
with  the  truth  we  need,  and  thus  force  us  to  have  recourse  to 
new  attempts  to  discover  it. 

We  conclude  by  remarking  that  nothing  is  more  difficult  than 
to  make  a  diagnosis  of  inflammation  of  the  liver,  and  to  prove  its 
existence  in  infants,  by  post  mortem  examinations  ;t  that  yellow 
and  green  evacuations  exist  almost  always  in  inflammation  of  the 
intestines  ;  that  it  is  not  proved  to  be  the  result  of  disease  of  the 
liver ;  that  it  is  much  better,  when  in  doubt,  to  consider  these 
symptoms  as  those  of  enteritis,  and  to  treat  the  child  accordingly, 
rather  than  to  imagine  the  diarrhoea  to  be  the  result  of  an  afflux 
of  irritating  bile  into  the  intestinal  canal,  which  it  is  necessary  to 
expel  by  purging. 

Several  authors  have  spoken  of  abscesses  in  the  hver  in  young 
infants  affected  with  icterus.^  But  as  M.  Denis  has  observed, 
autopsical  examinations  have  not  proved  the  existence  of  this 
lesion.  There  is  still  another  fact  pointed  out  by  authors,  it 
is  the  co-existence  of  the  diseases  of  the  duodenum,  and  liver. 
M.  Cruveilhier  has  observed  that  in  infants  affected  with  a 
softening  of  the  duodenum,  there  existed  at  the  same  time  a 
morbid  paleness  of  the  liver.  M.  Denis  also  entertains  this 
opinion,  but  it  is  necessary  here  to  obtain  a  correct  idea  of 
this  softening.  I  will  observe  here  first,  that  I  found  the  hver 
in  a  very  variable  condition  in  children  affected  with  duo- 
denitis.    Some   of  these,  who   form  the   objects  of  the  cases 

*  Dewees,  p.  367.    See  Appendix,  page  580. 

t  This  distinction  is  not  much  easier  in  adults,  v;  Andral.  clinic,  medie.  t.  4. 

t  Baumes,  Ictere  des  enfans  de  naissance.    Paris,  1806. 


ON   THE    DISEASES    OP    INFANTS.  341 

enumerated  above  were  affected,  as  I  have  already  said,  with 
phlegmasia  of  the  duodenum ;  but  we  ought  to  call  to  mind  the 
great  variety  of  appearance  which  the  liver  presented.  As  to 
the  softening,  I  am  not  of  the  opinion  of  MM.  Cruveilhier  and 
Denis,  if  they  allude  to  inflammatory  softening,  that  which 
follows  greater  or  less  intense  inflammation  of  the  mucous  mem- 
brane of  the  intestines ;  but  if  they  refer  to  the  white  softening, 
it  is  quite  another  thing ;  all  the  organs,  and  every  part,  are 
blanched  and  exsanguineous,  and  it  is  not  surprising  to  find  the 
liver  also  in  the  same  condition. 

I  do  not  speak  here  of  icterus  of  young  infants,  because  I  do 
not  consider  it  as  a  symptom  of  an  affection  of  the  liver.  I  shall 
examine  this  subject  hereafter. 

The  gall-bladder  appears  to  me  to  be  seldom  diseased  ;  I  have 
not  often  had  occasion  to  observe  its  congenital  malformation ; 
M.  Denis  mentions  his  having  met  with  its  absence  in  three 
instances.  It  is  sometimes  very  slightly  developed  and  reduced 
to  a  small  globular  pouch  ;  generally  its  walls  are  colored  green 
by  the  bile,  and  its  internal  surface  covered  with  a  thick  layer 
of  mucosity ;  its  walls  are  in  this  case  thin  and  transparent ;  and 
vascular  ramifications  more  or  less  numerous  are  seen  on  its  sur- 
face. I  once  found  in  the  dead  body  of  a  child  whose  case  I  had 
not  particularly  noted,  the  gall-bladder  evidently  inflamed ;  its 
internal  surface  presented  a  bright  redness,  and  the  thickness  of 
its  walls  was  considerably  increased.  It  is  very  common  to  find 
in  it  a  very  minute  spotted  redness,  which  can  scarcely  be  seen 
except  after  removing  the  bile  which  generally  covers  the  sur- 
face of  this  viscus. 

Alterations  of  the  biliary  ducts,  such  as  stricture,  obliteration, 
and  inflammation,  occur  much  more  frequently  in  adults  and  old 
men  than  in  young  infants. 

Diseases  of  the  spleen  and  pancreas,  which  are  also  appen- 
dages to  the  intestinal  tube,  have  not  furnished  me  with  any 
thing  worthy  of  notice :  congestions  of  the  former  are  the  disor- 
ders most  usually  observed.  I  have  cited  an  instance  of  its  rup- 
ture in  consequence  of  this  pathological  state. 

In  infants  at  the  period  of  birth,  the  pancreas  exhibits  a  devel- 
opment considerably  advanced ;  I  do  not  doubt  that  it  concurs 
in  the  performance  of  the  digestive  functions,  and  pours  its  secre- 


342  ON    THE    DISEASES    OP    INFANTS. 

tion  into  the  intestinal  canal ;  but  I  have  been  unable  to  prove 
whether  the  absence  or  superabundance  of  this  secretion  in  any 
way  disturbs  the  functions  of  the  intestinal  tube.  It  would  be  a 
curious  fact  to  prove  in  serous  or  mucous  diarrhoea  of  infants, 
that  the  secretion  of  the  pancreas  united  with  that  of  the  follicu- 
lar apparatus  of  the  intestines,  to  form  the  abundant  and  liquid 
nature  of  the  stools. 


CHAPTER  IV. 

DISEASES    OF    THE    URINARY    APPARATUS. 
Art.  1. — Development. 

This  apparatus  comprises  the  renal  capsules,  kidneys,  ureters, 
bladder,  urachus  and  urethra. 

At  two  months  the  venal  capsules  begin  to  be  distinct  in  the 
embryo  ;  they  are  even  larger  and  heavier  than  the  kidneys ; 
but  their  size  gradually  diminishes,  and  the  kidneys,  on  the  con- 
trary, become  more  voluminous,  so  that  at  birth  the  kidneys  are 
three  times  the  bulk  of  the  capsules.  They  contain,  at  first,  a 
viscid  fluid,  which  almost  entirely  fills  them  ;  but  this  fluid  being, 
by  degrees,  reabsorbed,  leaves  nothing  but  a  thick  brown  layer 
spread  over  the  internal  surface  of  the  capsule ;  when,  therefore, 
the  renal  capsules  of  a  young  infant  are  examined,  there  is  al- 
ways found  in  them  the  soft  brown  substance  just  alluded  to, 
and  which  presents  great  variety  in  appearance.  Sometimes  it 
is  of  the  color  of  chocolate  ;  sometimes,  on  the  contrary,  it  re- 
sembles cerebral  substance  mixed  with  blood.  It  is  often  found 
so  white  and  soft  as  to  be  liable  to  be  mistaken  for  pus.  The 
substance  does  not  melt  by  heat,  nor  will  it  grease  silk  paper,  and 
appears  to  be  rather  of  a  fibrous  nature,  analogous  to  that  of  the 
blood,  rather  than  a  serous,  mucous,  or  adipose  fluid.  We  must 
be  careful  not  to  consider  it  as  the  result  of  a  morbid  secretion, 
or  of  a  disorganization  of  tissue.  The  external  appearance  of 
these  organs  is  of  a  reddish  yellow  or  light  brown ;  they  are 
usually  rugous  or  wrinkled  ;  they  are  so  tender  as  to  be  easily 


ON   THE    DISEASES    OP    INFANTS.  343 

torn.  This  consistence,  therefore,  ought  not  to  be  taken  for  a 
morbid  softening.  With  Meckel,  I  am  of  opinion  that  they  have 
no  cavity ;  at  least  it  is  hardly  a  cavity  which  contains  the  semi- 
fluid matter  throughout  the  interior  of  these  capsules. 

The  kidneys,  which  do  not  appear  until  after  the  renal  cap- 
sules— that  is  to  say,  between  the  second  and  third  month — are  at 
first  composed  of  a  number  of  hollow  lobules  communicating 
freely  among  themselves,  and  which  are  connected  by  a  tissue 
very  easily  separated.  The  lobules,  approaching  afterwards 
more  closely,  are  confounded,  as  it  were,  one  with  the  other,  and 
become  less  numerous  ;  the  openings  between  them  are  smaller, 
presenting  very  shortly  a  small  hole  which  opens  into  the  com- 
mon reservoir,  the  pelvis.  During  the  formation  of  this  union 
of  the  lobules  of  the  kidney,  the  cortical  substance  forms  gradu- 
ally ;  it  is  very  evident  at  six  months.  It  is  to  be  remarked  that 
these  lobules  secrete  interiorly,  and  at  an  early  period,  a  white 
serous  fluid  which  distends  them,  but  which  is  forced  out  in  pro- 
portion as  the  cortical  substance  forms,  the  thickness  of  the  walls 
of  the  lobules  increases,  and  their  cavities  diminish  ;  it  is  proba- 
ble that  this  fluid  flows  into  the  pelvis  of  the  kidney,  and  thence 
into  ureters  and  bladder. 

The  bladder  exists  at  a  very  early  day  ;  it  appears  at  first  un- 
der the  form  of  a  small  distinct  pouch,  when  the  kidneys  are 
scarcely  formed.  At  this  time  it  is  a  kind  of  continuation  of  the 
urachus,  which,  from  the  very  first  formation  of  the  embryo,  is 
large  and  distinct  towards  the  umbilical  cord,  and  afterwards  di- 
minishes progressively,  and  becomes  obliterated  to  sueh  a  degree 
that  anatomists,  who,  without  doubt,  observed  it  only  at  the  pe- 
riod of  birth,  have  denied  its  existence  as  a  canal. 

The  ureters  and  urethra,  which  are  appendages  to  the  differ- 
ent hollow  organs  just  examined,  are  found  as  soon  as  these  or- 
gans and  these  canals  enlarge,  which  enlargement  occurs  in  pro- 
portion to  the  growth  of  the  infant. 

Malformations. — Malformations  of  the  urinary  apparatus  fre- 
quently appear  in  infants.  As  this  system  is  composed  of  several 
parts  closely  united  together  both  by  their  anatomical  relations 
and  their  functions,  malformation  of  one  of  these  parts  is  often 
connected  with  a  deformity  of  some  of  the  others.  Thus  it  is 
that  the  kidneys  are  often  the  seat  of  organic  deviations  which 


344  ON   THE   DISEASES   OF    INFANTS. 

result  from  congenital  malformations  of  the  ureters,  bladder,  or 
urethra.  We  shall  hereafter  give  one  example  of  this.  The 
primitive  arrangement  of  the  constituent  parts  of  the  organ  suf- 
ficiently explains  the  congenital  malformations. 

I  have  already  remarked  that  the  kidneys  were  composed  pri- 
mitively of  several  lobules,  on  the  internal  surface  of  which  is 
secreted  a  fluid  which  flows  through  the  ureters  into  the  bladder ; 
but  if  the  ureter  presents  an  interruption  or  an  obliteration  of  its 
canal,  this  fluid  then  remains  in  the  lobule,  distends,  and  it  be- 
comes vesicular,  opposes  the  free  development  of  the  cortical  sub- 
stance, and  in  place  of  a  kidney^  on  opening  the  dead  body,  a 
mass  of  transparent  vesicles  is  found,  irregularly  agglomerated 
with  each  other,  communicating  more  or  less  directly  with  the 
pelvis  of  the  kidney,  constituting  a  true  congenital  encysted 
dropsy,  as  will  be  seen  in  the  following  case. 

CASE  LIII. — Congenital  malformation  of  the  kidney,  oblitera- 
tion of  the  ureter. — Jules  Martin,  aged  four  days,  entered  the  infir- 
mary. He  was  strong ;  the  integuments  highly  colored  ;  at  the 
kimbar  region  there  existed  a  round  tumor,  soft  to  the  touch,  exhib- 
iting at  the  centre  a  red  excoriation,  and  at  the  circumference  a  hard, 
red,  and  irregular  ring.  This  child  remained  at  the  infirmary  for 
one  month  ;  during  this  time  he  became  thin,  and  insensibly  wasted 
away ;  there  also  existed  at  first  vomiting  and  diarrhoea  ;  the  cry 
was  feeble,  and  the  circulation  very  slow;  he  died  on  the  1st  of 
March.  On  the  post  mortem  examination,  there  was  found  a  con- 
siderable effusion  of  serosity  in  the  lateral  ventricles,  through  the 
extent  of  the  spine,  and  in  the  tumor  which  existed  in  the  lumbar 
rfegion  at  the  spinous  processes  of  the  last  lumbar  and  first  sacral  ver- 
tebrae. There  was  nothing  remarkable  in  the  digestive  apparatus, 
but  the  urinary  system  presented  the  following  arrangement. 

The  left  kidney  consisted  of  a  mass  of  the  size  of  a  goose's  eg^, 
of  semitransparent  lobules,  irregularly  agglomerated,  forming  seve- 
ral small  cysts  filled  with  a  white  inodorous  fluid.  These  cysts  com- 
municated freely  with  one  another ;  those  nearest  to  the  pelvis 
opened  into  this  reservoir,  which  itself  was  filled  with  a  fluid  re- 
sembling that  in  the  cysts.  The  kidneys  retained  no  trace  of  their 
natural  texture  ;  yet  towards  the  fissure  their  existed  a  layer  of  cel- 
lular tissue  of  a  tolerable  thickness,  and  as  if  condensed.  It  was  in 
this  tissue  that  the  renal  artery  and  vein  terminated,  and  were  abli- 
terated.    I  searched  in  vain  for  the  connection  of  the  ureter  with  the 


ON   THE    DISEASES    OF    INFANTS.  345 

pelvis  ;  the  latter  formed  a  true  cul-de-sac.  The  ureters  were  well 
developed  near  the  bladder,  in  which  they  opened  as  usual ;  but  in 
ascending  towards  the  kidneys  they  were  observed  to  degenerate 
into  two  small  thin  cords,  bifurcated  and  without  any  perforation,  and 
near  the  pelvis  these  filaments  became  quite  numerous,  and  WQje 
applied  to  the  kidneys  in  the  form  of  a  goose's  foot. 

The  right  kidney  was  more  developed  than  usual ;  the  bladder 
slightly  dilated,  contained  a  little  turbid  urine,  in  which  was  found  a 
large  quantity  of  gravel  as  fine  as  sand  ;  the  lungs  were  slightly 
gorged  with  blood  ;  the  fcetal  openings  were  obliterated. 

This  encysted  dropsy  of  the  kidneys  was  remarkable  by  reason 
of  its  coexistence  with  an  imperforation  and  obliteration  of  the 
ureter.  This  case  furnishes  an  instance  of  double  malformation 
of  the  urinary  apparatus,  but  the  one  appears  to  be  the  result  of 
the  other,  and  I  am  of  opinion  that  renal  dropsy  is  the  effect  of  a 
retention  of  the  fluid  that  has  not  found  an  outlet  neither  by  the 
pelvis  or  ureters.  We  ought  also  to  note  the  presence  of  gravel 
in  the  urine  in  this  case. 

When  the  urine  is  obstructed  in  its  course  at  any  other  part 
of  the  urinary  passages,  it  is  easily  conceived  that  the  parts  above 
the  obliteration  will  present  a  dilatation  analogous  to  that  we 
have  just  been  considering.  The  following  observation  is  in 
point. 

CASE  LIV. — In  dissecting  the  body  of  a  male  infant,  born  dead, 
which  M.  Delpech,  physician  at  Paris,  sent  to  M.  Baron  on  the  10th 
of  June,  1826,  I  made  the  following  observations.  The  head  was 
small  in  size  ;  the  limbs  very  thin ;  the  integuments  flabby  and 
slightly  purple ;  the  abdomen  excessively  distended,  formed  a  round 
projecting  tumor,  presenting  the  appearance  of  a  kind  of  circular 
"cone,  the  umbilicus  forming  the  apex.  The  insertion  of  the  umbili- 
cal cord  was  very  large.  A  very  evident  fluctuation  was  felt  in  this 
tumor.  In  every  other  respect  the. body  exhibited  all  the  characters 
of  a  child  born  at  the  full  term. 

On  opening  the  body,  a  vast  pouch  was  seen  filling  all  the  abdomi- 
nal cavity,  and  the  intestines  were  crowded  by  it  backward  and  up- 
ward. On  the  anterior  lateral  part  of  this  pouch,  the  vesiculae  se- 
minales  were  found  attached,  and  at  the  inferior  lateral  part  of  this 
cyst,  the  vassa  defferentia   appeared,  together  with   the   testicles. 

Lastly,  near  the  summit  of  this  cyst,  and  directly  between  the  two 

4.4 


346  ON   THE    DISEASES   OF    INFANTS. 

vesiculae  seminales,  was  seen  the  rectum,  very  large,  and  distended  by 
a  large  quantity  of  meconium,  adhering  solidly  to  the  walls  of  this 
voluminous  pouch,  and  obliterated ;  which  was  discovered  to  be  the 
bladder,  and  was  also  enormously  distended  by  a  white  fluid,  which 
did  not  alter  the  color  of  litmus  paper ;  this  fluid  contained  some 
white  ropy  mucosity,  and  the  internal  surface  of  the  bladder  was 
covered  with  a  layer  of  adherent  mucus.  The  interior  orifice  of  the 
urethra  did  not  exist ;  on  examining  the  canal,  I  was  only  able  to 
pass  the  stylet  of  a  female  catheter  about  half  an  inch,  and  I  disco- 
vered, on  dissection,  that  the  passage  became  gradually  narrowed 
from  the  extremity  of  the  penis,  and  finally  became  obhterated,  ter- 
minating in  a  filament,  lost,  as  it  were,  in  the  cellular  tissue  of  the 
perinseum.  I  was  unable  to  discover  the  prostrate  gland  ;  at  least  I 
could  not  consider  a  sort  of  reddish  tissue,  adherent  to  the  bladder 
behind  the  insertion  of  the  rectum,  as  this  organ.  The  openings  of 
the  ureters  into  the  bladder  were  perfect ;  their  diameter  was  large 
and  insensibly  increasing  to  the  kidney,  and  on  each  side  was  nearly 
as  large  as  a  hen's  egg,  exhibiting  the  same  lobular  structure  as  the 
preceding  case.  Yet  the  lobules  were  smaller,  less  transparent,  and 
were  in  part  covered  with  the  cortical  substance,  but  the  infundibuli 
and  pelvis  were  much  larger  and  more  distended  than  natural.  A 
white  inodorous  fluid  filled  the  vesicular  lobules,  which  had  a  free 
communication  with  each  other,  and  opened  into  the  pelvis ;  the 
urachus  existed  only  as  a  small  obliterated  conduit. 

There  was  no  anus,  and  the  rectum,  examined  interiorly,  present- 
ed a  complete  cul-de-sac,  closely  adherent  to  the  bladder.  There 
was  nothing  remarkable  in  the  other  organs. 

In  this  child  it  appears  that  the  obliteration  of  the  urethra 
caused  the  dropsy  of  the  bladder,  and  the  latter,  the  hydropic  af- 
fection of  the  kidneys,  the  normal  development  of  which  was 
hindered  or  even  suspended.  The  bladder,  in  distending  and  in 
acquiring  the  size  which  it  exhibited,  appeared  to  have  moved 
from  its  situation  forward  and  upward ;  so  that  the  base  was 
found  elevated,  and  drawing  with  it  every  part  that  was  adherent 
inferiorly ;  they  were  in  this  way  drawn  out  of  their  natural 
situation ;  hence  the  situation  of  the  vesicuhr  seminales  and  the 
rectum  at  the  superior  part,  and  the  opening  of  the  ureters  at  the 
lateral  and  anterior  part.  Thus  several  disorders  resulted  from 
an  original  malformation — involving  not  only  the  portions  of 


ON   THE    DISEASES    OF    INFANTS.  347 

the  same  apparatus,  but  likewise  organs  which  had  only  the  re- 
lation of  contiguity  with  these  parts. 

This  case,  as  well  as  the  preceding,  will  serve  to  prove  that 
the  excretions  of  the  fcBtus,  at  least  those  of  the  urinary  organs, 
are,  in  the  normal  condition,  rejected  from  the  body,  and  proba- 
bly are  mixed  with  the  waters  of  the  amnios,  since  it  appears 
that  when  any  obstacle  occurs  to  the  passage  of  this  fluid,  it  re- 
flows  into  the  reservoirs,  and  distends  them  excessively,  in  the 
same  manner  as  is  observed  in  adults  who  are  affected  with  a 
stricture  of  the  urethra,  or  paralysis  of  the  bladder.  This  re- 
mark ought  to  have  a  place  in  the  history  of  embryology. 

The  urinary  passages  may  also  present  other  congenital  mal- 
formations, for,  as  M.  Meckel  observes,  the  urinary  apparatus  is 
one  of  those  which  presents  the  greatest  anomalies.  The  kid- 
neys are  sometimes  absent,  or  if  there  is  but  one,  it  is  generally 
found  on  the  median  line,  and  close  to  the  vertebral  column. 
They  are  more  or  less  voluminous ;  their  lobules  are  sometimes 
widely  separated :  their  situation,  likewise  varies,  the  effect  of 
different  causes  ;  thus,  for  instance,  they  are  drawn  below  or 
crowded  towards  the  diaphragm,  in  consequence  of  adhesion 
which  they  may  contract  with  the  surrounding  parts. 

Absence,  imperfection,  occlusion,  or  plurality  of  the  ureters, 
have  been  pointed  out  in  the  preceding  observations. 

In  addition  to  the  distension  and  displacement  of  the  bladder, 
this  organ  sometimes  exhibits  a  congenital  malformation,  of 
which  Chaussier,  Duncan,  and  other  authors  have  given  instan- 
ces. I  allude  to  extrusion  of  the  bladder.  The  anterior  portion 
is  absent ;  at  the  same  time  there  exists  a  division  of  the  abdomi- 
nal parietes,  or  a  separation  of  the  pubis  opposite  the  bladder,  so 
that  this  organ  exhibits,  on  the  outside  of  the  abdomen,  the  inter- 
nal surface  of  its  posterior  wall,  which  is  red  and  studded  with 
mamillary  protuberances,  and  the  orifice  of  the  ureters  are  often 
seen,  from  which  the  urine  continually  issues.  This  malforma- 
tion is  met  with  not  only  in  males,  as  Duncan  asserts,*  but  is 
also  found  to  exist  in  females. 

Meckel  observes  that  the  bladder  has  been  seen  bifurcated  or 


*  Med.  and  Surg.  Journal,  1805,  Edinburgh. 


348  ON    THE    DISEASES    OF    INFANTS. 

formed  into  several  sacs.*  These  malformations  are  so  much 
the  more  dangerous  in  young  infants,  as  they  offer  a  greater  ob- 
stacle to  the  course  of  the  urine. 

The  urethra  may  be  either  more  or  less  completely  obliterated, 
or  may  present  only  a  stricture  of  its  canal.  The  orifice  may 
be  met  with  in  any  portion  of  the  inferior  part  of  the  penis  in- 
stead of  the  glans.  This  malformation  has  received  the  name 
of  hypospadias,  In  such  a  case,  the  glans  is  almost  always  de- 
formed ;  it  is,  as  it  were,  curved  downward,  so  that  the  urine 
generally  falls  between  the  legs,  instead  of  being  thrown  for- 
wards. 

When  a  child  is  born  with  an  imperforate  urethra,  it  will  be 
necessary  to  form  an  artificial  opening,  either  at  the  extremity 
of  the  penis,  if  the  passage  runs  as  far,  or  at  any  other  part  of 
the  penis  ;  for  it  is  much  better  to  establish  a  hypospadias,  than 
to  abandon  the  child  to  death,  which  must  certainly  ensue  from 
a  suspension  of  the  course  of  the  urine.  The  existence  and 
length  of  the  canal  may  be  ascertained  by  the  feeling  of  fluctua- 
tion which  is  experienced  on  moving  the  fingers  along  the  under 
part  of  the  penis.  If  the  abdomen  is  distended  by  the  develop- 
ment of  the  bladder,  and  should  it  appear  impossible  to  open  the 
urethra,  the  puncture  of  the  bladder  ought  to  be  attempted,  either 
above  the  pubis  or  through  the  rectum.  The  latter  method  is 
perhaps  the  best ;  it  will  succeed  in  prolonging  the  days  of  the 
child,  particularly  if  the  opening  between  the  bladder  and  rec- 
tum is  maintained,  because  the  urine  may  thereby  have  a  con- 
stant outlet  by  this  organ.  In  every  instance  these  curative 
measures  can  have  but  a  temporary  efiicacy,  and  will  not  pre- 
vent the  child  from  sinking,  sooner  or  later,  under  this  serious 
imperfection. 

DISEASES    OF    THE     URINARY    APPARATUS. 

It  is  probable  that,  during  the  intra- uterine  life,  both  the  kid- 
neys and  bladder  may  become  inflamed,  but  it  is  very  difficult, 
particularly  with  respect  to  the  kidneys,  to  prove  the  existence 
of  this  inflammation  in  young  infants  ;  indeed  the  kidneys  may 
be  more  or  less  colored,  in  proportion  to  the  abundance  or  ab- 

•  S.  A.  Ehrlich,  Chirurgische  Beobachtungen,  v.  2,  p.  123. 


ON    THE    DISEASES    OF    INFANTS.  349 

sence  of  blood  in  their  tissue.  I  have  often  observed,  on  the  sur- 
face of  the  kidneys  of  newly  born  children,  ecchymoses  of  great- 
er or  less  extent,  attributable  to  the  effusion  of  blood  beneath 
their  proper  covering ;  often,  also,  there  are  seen  red  spots  on  the 
papillae,  frequently  of  so  great  a  size  as  to  be  regarded  as  true 
petechiee. 

There  is  a  very  remarkable  alteration  of  color,  which  is  seen 
in  infants  affected  with  icterus ;  shining  yellow  striae  are  ob- 
served to  spread  in  rays  from  the  summit  to  the  base  of  the  pa- 
pillae, which,  without  doubt,  are  owing  to  the  coloring  of  the 
serosity  between  the  jfibres  of  the  papillary  substance.  These 
colored  strias  are  uniformly  in  one  direction  ;  they  must  not  be 
regarded  as  the  result  of  any  particular  alteration  in  the  tissue 
of  the  kidneys,  but  as  the  effect  of  a  remote  cause  which  produ- 
ces jaundice.  I  once  saw  the  cortical  separated  from  the  papil- 
lary substance  by  a  yellow  line,  analogous  to  that  of  which  I 
have  just  spoken  :  the  papillas  appeared  as  if  enveloped  by  a  fes- 
tooned line. 

I  have  several  times  found  the  kidneys  in  young  infants  so 
soft  that  they  were  torn  upon  the  least  effort. 

It  would  seem  as  if  calculous  nephritis  might  be  developed 
even  during  intra-uterine  life  ;  such  was  in  truth  the  fact  with 
the  child  mentioned  in  case  liii.,  in  whose  bladder  a  quan- 
tity of  gravel  was  found.  M.  Denis  has  often  found  gravel  in 
the  urinary  passages  and  in  the  urine  of  young  infants.  I  have 
also  frequently  found  them,  but  never  saw  calculi,  properly  so 
called  ;  still  I  think  it  not  impossible  for  them  to  exist. 

The  bladder  in  new-born  children  is  usually  small  and  con- 
tracted ;  it  is  scarcely  elevated  above  the  superior  strait  of  the 
pelvis ;  its  internal  surface  is  remarkable  for  its  white,  satin-like 
appearance,  entirely  different  from  that  of  other  abdominal  or- 
gans, which  are  almost  always  more  or  less  injected  at  the  period 
of  birth.  Once  only  I  found  petechias  ;  but  they  existed  also  in 
other  parts  of  the  body  at  the  same  time. 

After  birth,  the  kidneys  and  bladder  sometimes  become  in- 
flamed, but  phlegmasiae  of  these  organs  are  much  more  rare  in 
the  infant  at  the  breast  than  those  of  other  organs. 

The  symptoms  which  Willan  and  Underwood  have  attributed 
to  ischuria  renales  in  children  appear  to  me  to  be  those  of  a  true 


350  ON    THE    DISEASES    OP    INFANTS. 

nephritis,  at  least  we  must  so  infer  from  the  symptoms  described, 
and  the  success  of  the  treatment  employed.  If  infants  have 
died,  as  Underwood  says,  without  any  evidence  of  pain  or  any 
particular  uneasiness,  it  shows  that  the  most  serious  inflamma- 
tions may  arise  without  giving  evidence  of  any  well-marked  re- 
action. 

When  the  suspension  of  urine  arises  from  an  affection  of  the 
kidneys,  in  consequence  of  which  their  functions  are  suspended, 
although  no  urine  passes,  yet  the  bladder  does  not  become  dis- 
tended, so  that  the  fluid  is  not  really  secreted  in  so  great  a 
quantity  as  in  the  natural  state. 

I  have  not  traced  with  great  accuracy  the  symptoms  of  cystitis 
in  infants  at  the  breast,  as  I  have  not  been  able  to  observe  them 
with  sufficient  care,  either  because  they  have  not  been  very  evi- 
dent in  the  young  subjects  submitted  to  my  notice,  or  have  been 
concealed  by  other  symptoms  ;  but  I  have  often  found  the  blad- 
der inflamed  in  opening  the  bodies  of  children  at  a  different  age. 
This  inflammation  was  characterized  by  an  intense  redness,  a  well- 
marked  tumefaction  of  the  internal  membrane,  which  was  torn 
and  separated  in  shreds  with  the  greatest  facility.  I  observed 
particularly  in  three  infants  aged,  one  hfteen  days,  another  two 
months,  and  the  third  four  months,  where  the  bladder  was  dis- 
tended by  a  large  quantity  of  urine,  a  very  high  inflammation 
of  the  neck  of  the  bladder,  which  was  red  and  very  much  swelled, 
which  led  me  to  believe  that  these  children  had  been  affected 
with  cystitis,  and  following  it  a  retention  of  urine  to  which 
they  succumbed.  The  greatest  care  must  therefore  be  observed 
in  studying  the  causes  of  retention  of  urine  in  infants,  in  order 
to  render  the  necessary  assistance  for  its  removal.  We  should 
endeavor  to  distinguish  retention  produced  by  cystisis,  from  that 
which  has  its  cause  in  the  paralysis  of  the  bladder  arising  from 
the  existence  of  an  acute  or  chronic  affection  of  the  cerebro-spinal 
apparatus. 

It  would  appear  from  the  remarks  and  observations  of  Morton, 
that  infants  may  be  affected  with  diabetes  mellitis,  a  disease  cha- 
racterized, he  says,  by  a  rapid  emaciation,  an  abundant  diarrhosa, 
an  urgent  thirst,  and  a  great  discharge  of  urine,  which,  as  in 
adults,  possesses  a  saccharine  quality. 

Catarrh  of  the  bladder  is  very  rare  in  infants  at  the  breast ; 


ON   THE    DISEASES    OF    INFANTS.  351 

it  is  more  frequent  in  children  more  advanced  in  age,  whether  it 
be  idiopathic,  or  whether  it  be  caused  by  the  presence  of  a  cal- 
culus in  the  bladder. 

The  treatment  of  these  various  affections  is  very  easy  :  thus, 
acute  cystitis  which  may  be  recognised  by  a  painful  tension  of 
the  hypogastrium,  and  suspension  of  urine,  will  be  advanta- 
geously treated  by  the  application  of  one  or  two  leeches  to  the 
perinaeum,  and  the  use  of  warm  baths  and  emollient  cataplasms 
to  the  abdomen.  When  there  exists  a  paralysis  of  the  bladder, 
recourse  must  be  had  to  the  catheter,  together  with  such  measures 
as  will  be  necessary  to  meet  the  cerebral  affection  of  which  the 
paralysis  is  the  effect;  and  lastly,  if  diabetes  as  described  by 
Morton  be  recognised,  the  treatment  recommended  by  that  cele- 
brated practitioner  should  be  adopted.  The  method  of  treating 
a  child  that  he  cured,  consisted  of  a  diet  of  milk,  to  which  the 
patient  was  strictly  kept  from  the  commencement  of  the  disease, 
and  the  only  drink  that  was  allowed  to  quench  the  thirst  with 
which  it  was  incessantly  tormented,  was  a  mixture  of  honey  and 
the  ferruginous  water  of  Islington. 

New-born  children  are  sometimes  affected  with  retention  of 
urine,  arising  neither  from  inflammation  nor  paralysis  of  the 
bladder ;  they  are  often  two  or  more  days  without  passing  any 
urine.  In  a  case  of  this  kind,  when  we  are  satisfied  that  the 
natural  passage  exists,  it  will  be  necessary  to  place  the  child  in  a 
warm  bath,  and  to  apply  a  poultice  to  the  abdomen,  or,  as  is 
advised  by  Underwood,  a  bladder  partially  filled  with  warm 
water.* 

When  infants  are  affected  with  gravel  or  urinary  calculi,  it 
will  be  difficult  to  adopt  the  course  of  treatment  necessary  for 
such  disorders ;  how,  indeed,  can  young  children,  whose  sole 
nourishment  is  milk,  be  submitted  to  a  watery  vegetable  diet, 
as  recommended  by  M.  Magendie  ?  This  disease  is  doubtless 
very  dangerous  at  this  early  age,  and  we  cannot  expect  to  re- 
move the  cause,  but  in  proportion  as  the  advance  of  age  enables 
us  to  vary,  modify,  and  select  their  food.  Nevertheless,  the 
nurse  should  be  kept  from  the  use  of  fat  meats,  and  such  as 
abound  in  azote,  and  use  exclusively  vegetable  diet. 

*  See  Appendix,  page  593. 


352  ON   THE   DISEASES   OF    INFANTS. 

CHAPTER  V. 

PERITONITIS. 

Inflammation  of  the  peritoneum  is  more  common  than  is 
generally  believed  ;  and,  not  only  is  it  developed  after  birth  un- 
der the  influence  of  the  exciting  causes  to  which  the  child  is 
subjected,  but  it  may  likewise  exist  during  the  intra-uterine  life, 
as  will  be  seen  in  the  following  instances. 

Conge7iital  peritonitis. — I  have  seen  in  the  dead  body  of  two 
children,  that  died,  the  one  eighteen  hours,  and  the  other  twenty- 
four  hours  after  birth,  old  and  very  firm  adhesions  between  the 
different  convolutions  of  the  intestines,  and  in  one  of  them  the 
convex  surface  of  the  liver  adhered  firmly  to  the  interior  walls 
of  the  abdomen.  These  accidental  adhesions  must  be  considered 
as  the  result  of  peritonitis  developed  during  intra-uterine  life,  and 
which  had  passed  through  its  different  stages  before  birth.  One 
of  these  children  was  thin,  small,  and  very  pale;  but  the  other 
exhibited  the  usual  appearance  of  infants  at  birth. 

Acute  peritonitis  in  children  has  to  appearance  often  been 
brought  with  them  from  birth.  M.  Duges,  in  his  essay  on  the 
diseases  of  children,  where  will  be  found  a  very  interesting  chap- 
ter devoted  to  the  history  of  peritonitis  of  new-born  children,  has 
reported  the  case  of  a  child  born  on  the  9th  of  February,  1821, 
at  the  Maternite,  between  the  seventh  and  eighth  month,  well- 
formed,  about  sixteen  inches  in  length,  weighing  three  pounds 
and  a  half  It  was  aifected  with  a  general  oedema ;  the  abdomen 
was  tense  ;  and  although  the  child  had  respired,  cried,  and  lived 
for  three  hours,  it  had  passed  no  meconium ;  yet  it  had  received 
and  passed  a  tepid  enema.  The  post  mortem  examination  was 
made  on  the  ensuing  day,  in  the  presence  of  professor  Chaussier. 
"All  the  abdominal  viscera,"  says  M.  Duges,  "were  agglutinated 
by  yellow  concrete  albumen.  False  membranes  were  found 
attached  to  the  liver,  spleen,  bladder,  <fec.  The  epiphora  was 
adherent  to  the  intestines ;  the  latter  were  joined  together  in  a 
bundle,  and  were  yellow,  hard,  and  thick  ;  their  tissue  appeared 
to  be  mixed  with  concrete  albumen ;  and  they  contained  a  yellow 
frothy  mucus,  etc." 


ON   THE    DISEASES    OF    INFANTS.  353 

This  infant  was  a  first  child :  the  mother  twenty-two  years 
of  age,  and  in  good  health,  having  been  subject  only  to  chil- 
blains, and  sometimes  to  pimples  on  the  hands.* 

I  have  seen  peritonitis  to  the  same  extent  in  three  infants  that 
died  a  short  time  after  birth,  and  who  were  all  quite  vigorous ; 
the  post  mortem  examination  alone  revealed  the  cause  of  their 
death.  In  one  of  them,  sero-purulent  effusion  was  very  abun- 
dant ;  the  intestines  were  very  red  exteriorly,  and  had  already 
besfun  to  contract  adhesions. 

We  can  easily  believe  that  the  recent  adhesions  of  the  perito- 
neum in  the  case  cited  by  M.  Duges,  and  in  the  last  instances 
which  I  have  given,  were  indications  of  the  existence  of  acute 
phlegmasia,  developed  either  in  the  latter  period  of  pregnancy 
or  during  birth :  it  is  not  the  same,  however,  with  chronic  peri- 
tonitis accompanied  by  old  and  firm  adhesions,  of  which  I  have 
spoken,  and  which  has  passed  through  its  several  stages  in  the 
uterus.  But  what  can  be  the  exciting  cause  of  this  inflamma- 
tion ?  It  must  be  transmitted  firom  the  mother  to  the  child ;  if 
otherwise,  in  what  way  can  it  be  accounted  for  ? 

Peritonitis  developed  after  birth. — From  the  time  children  are 
subjected  to  the  stimulating  causes  which  surround  us,  their  in- 
fluence may  to  a  greater  or  less  extent  produce  irritation  and  in- 
flammation in  their  organs,  which  are  not  less  sensible  than  our 
own ;  we  ought  not,  therefore,  to  be  surprised  at  the  existence 
of  peritonitis  in  young  infants. 

It  appears  either  in  an  acute  or  chronic  state,  of  which  I  will 
give  instances. 

CASE  LV. — Acute  peritonitis. — Alexis  Sonnecourt  entered  the 
infirmary  on  the  I3th  of  February,  aged  fourteen  days.  This  child 
possessed  some  strength  ;  but  in  the  last  two  days  he  became  pale, 
vomited  all  the  drinks,  was  affected  with  an  infiltration  of  the  lower 
limbs,  and  the  expression  of  the  face  indicated  great  distress.  He 
was  continually  restless  ;  his  abdomen  was  tympanitic,  and  formed 
a  point  towards  the  navel ;  it  was  hard,  and  very  painful  to  the 
touch,  for  immediately  upon  pressing  it  the  child  cried,  became  red 
in  the  face,  and  respired  with  the   greatest  difficulty.     The  thorax 

*  Recherches  sur  les  maladies  les  plus  importanies  et  les  moins  connues  des  enfans 
nouveau-nes.    Paris,  182L 

45 


354  ON  THE   DISEASES  OP   INFANTS. 

resounded  throughout  its  whole  extent ;  the  skin  was  dry  and  burn- 
ing ;  the  pulse  could  not  be  distinguished  at  the  wrist,  and  the  beat- 
ing of  the  heart  was  very  obscure  through  the  stethoscope  ;  the  cry 
was  small,  feeble,  acute,  and  scarcely  to  be  heard  ;  there  were  no 
alvine  evacuations.  (Diet,  sweetened  water,  cataplasm  to  the  ahda- 
men,  bath.)  He  died  on  the  night  of  the  thirteenth.  On  examining  the 
body  on  the  following  day,  the  mouth,  oesophagus,  and  stomach  were 
found  healthy.  The  intestines  were  distended  by  a  great  quantity 
of  gas  ;  the  peritoneum  presented  no  redness  in  the  different  parts 
of  its  surface  ;  but  there  existed  recent  and  firm  adhesions  between 
the  convolutions  of  the  intestines,  a  thick  pseudo-membranous  layer 
on  the  mesentery,  and  nearly  two  ounces  of  a  sero-purulent  liquid 
efiused  in  the  cavity  of  the  abdomen.  The  brain  and  circulatory  ap- 
paratus were  healthy. 

Among  the  symptoms  of  this  peritonitis,  we  have  particularly 
remarked  the  painful  distension  of  the  abdomen,  the  absence  of 
diarrhcEa,  the  extreme  smallness  of  the  pulse,  and  the  painful  ex- 
pression of  the  physiognomy.  The  anatomical  lesions  were  here 
of  a  nature  too  evident  to  admit  of  a  doubt  as  to  the  existence  of 
peritonitis. 

CASE  LVI. — Chronic  peritonitis. — Josephine  Perrine,  aged  ten 
months,  of  a  good  size,  but  thin  and  pale ;  had  already  cut  the  two 
incisor  teeth  of  the  lower  jaw ;  was  suddenly  seized  with  dyspnoea. 
This  child,  usually  lively,  had  become  morose  and  fretful.  She 
entered  the  infirmary  on  the  22d  of  January,  1826.  The  abdomen 
was  tympanitic ;  the  respiration  a  little  difficult,  and  was  indistinctly 
heard  at  the  upper  part  of  the  right  side  of  the  chest ;  the  tongue  was 
dry,  pulse  small,  skin  burning ;  she  was  affected  with  diarrhoea  con- 
sisting of  green  and  mucous  foeces.  (Syrup  of  gum,  cataplasm  to 
the  abdomen,  milk  and  water.)  On  the  twenty- third,  the  diarrhoea 
became  more  light-colored  ;  on  the  twenty-fourth,  the  same  general 
symptoms,  but  without  fever ;  tension  of  the  abdomen,  facies  hippo- 
cratica,  forehead  wrinkled.  On  the  twenty-sixth,  deglutition  diffi- 
cult ;  retching  whenever  drinks  were  given  ;  cry  feeble.  The  isthmus 
of  the  fauces  appeared  of  a  bright  red.  Death  took  place  on  the 
morning  of  the  twenty-seventh. 

Post  mortem  examination. — Body  considerably  emaciated ;  ge- 
neral paleness  of  the  integuments  ;  nearly  two  ounces  of  yellow  se- 
rosity  was  found  in  the  abdomen.    Numerous  and  firm  adhesions  ex 


ON   THE    DISEASES    OF    INFANTS.  355 

isted  between  the  transverse  portion  of  the  colon  and  the  great  cur- 
vature of  the  stomach.  Some'  of  the  convolutions  of  the  small  intes- 
tines were  likewise  adherent,  but  in  a  less  solid  manner.  The  mu- 
cous membrane  of  the  stomach  was  of  a  pale  rose-color ;  that  of  the 
small  intestines  was  covered  with  red  striae,  and  a  number  of  slate- 
colored  spots  existed  in  the  whole  length  of  the  colon.  The  supe- 
rior and  inferior  maxillary  bones  were  so  soft  and  spongy,  that  they 
could  be  cut  as  easily  as  cartilage  ;  the  gums  were  not  inflamed  ;  the 
brain  contained  a  quantity  of  citron-colored  serosity  in  the  lateral 
ventricles  ;  the  substance  of  the  brain  was  very  much  injected  ;  the 
right  lung  was  engorged. 

It  appears  to  me  to  be  very  difficult  to  have  made  a  correct 
diagnosis  of  this  peritonitis,  which,  in  consequence  of  its  chronic 
state,  presented  but  slightly  marked  characters,  and  was  besides 
concealed  by  the  intestinal  inflammation  with  which  it  was  com- 
plicated. The  dyspnoea  was  perhaps  the  result  of  the  eff*usion, 
which,  in  the  abdomen,  would  impede  the  movements  of  the 
diaphragm,  particularly  when  the  abdominal  cavity  was  com- 
pressed with  the  hand  or  the  child's  clothes,  for  the  lungs  exhib- 
ited no  serious  lesion  that  could  explain  the  disordered  respira- 
tion with  which  the  child  had  been  distressed. 

M.  Duges  considers  constipation  as  one  of  the  causes  of  peri- 
tonitis in  young  infants.  In  support  of  this  opinion,  he  cites 
Some  very  striking  facts ;  but  besides  the  fact  that  constipation 
is  more  often  the  effect  than  the  cause  of  peritoneal  inflamma- 
tion, since  it  does  not  supervene  until  after  the  commencement 
of  this  phlegmasia, — how  does  it  happen  that  the  child  can  be 
affected  with  this  disease  in  the  womb,  when  constipation  is, 
without  doubt,  as  it  appears  after  birth,  the  result  of  a  distur- 
bance of  the  digestive  functions  ?  Obhteration  of  the  rectum  and 
internal  strangulation  of  the  intestines,  may  produce  this  disease, 
of  which  M.  Legouais  and  M.  Duges  have  seen  examples ;  but 
these  accidents  may  also  arise  without  inflaming  the  peritoneum, 
as  we  have  seen  in  the  cases  already  reported. 

It  is  very  difficult,  therefore,  to  explain  the  causes  of  peritoni- 
tis in  infants  at  the  breast.  There  is  one  circumstance  very  re- 
markable in  this  disease,  and  observed  by  M.  Duges  ;  it  is,  that 
children  aflTected  with  it  were  not  born  of  mothers  suffering  from 
puerperal  peritonitis. 


356  ON    THE    DISEASES    OF    INFANTS. 

The  symptoms  peculiar  to  peritonitis  are,  tension  of  the  abdo- 
men, which  rises  in  a  point  towards  the  umbilicus,  restlessness, 
pain,  indicated  by  a  pinched  face  and  the  increasing  cries  of 
the#  child,  vomiting,  eructation,  constipation,  and  lastly,  a  gen- 
eral sinking  and  smallness  of  the  pulse.  Such  are  the  symp- 
toms that  characterize  peritonitis,  and  which  require  the  closest 
attention  and  tact  on  the  part  of  the  physician  to  distinguish  it 
from  phlegmasia  of  the  intestinal  tube,  with  which  it  may  be 
complicated  and  confounded. 

Peritonitis  may  be  distinguished  from  pleurisy  by  the  full 
sound  of  the  thorax.  Dyspnoea,  as  we  have  seen  in  case  lv, 
does  not  always  indicate  an  affection  of  the  lungs  ;  it  may  arise 
from  a  tympanitic  state  of  the  abdomen  and  the  labored  move- 
ment of  the  diaphragm ;  and  the  abdominal  pains  being  con- 
stant, differ  from  those  caused  by  a  spasm  of  the  bowels,  and 
their  distension  with  gas,  for  in  the  latter  case  these  colic  pains 
are  almost  always  remittent,  and  cease  with  the  evacuation  of 
gas.  The  prognosis  of  peritonitis  in  infants  is  always  unfavo- 
rable. 

Treatment. — The  treatment  should  be  commenced  by  a  sus- 
pension of  sucking  ;  one  or  two  leeches  should  then  be  applied 
on  the  abdomen,  not  far  from  the  umbilicus,  and  the  child  placed 
in  a  warm  marshmallows  bath,  and  poultices  of  flaxseed  applied 
to  the  belly  ;  it  may  also  be  covered  with  a  little  oil  of  almonds, 
and  oil  of  chamomile,  as  recommended  by  M.  Chaussier.*  From 
two  to  three  grains  of  calomel  ought  then  to  be  given,  and  a  i^w 
spoonfuls  of  the  syrup  of  succory,  or  an  injection  of  castor  oil, 
or  honey  of  mercury,  to  procure  some  foecal  discharge,  and  there- 
by establish  a  point  of  revulsion  on  the  intestines ;  but  before 
having  recourse  to  these  means,  we  ought  to  be  well  assured  that 
we  have,  in  some  degree,  overcome  the  acute  inflammatory 
symptoms,  and  that  there  exists  no  enteritis. 

When  the  patient  is  convalescent,  we  should  return  gradually 
to  the  use  of  a  tonic  regimen  suited  to  the  age  of  the  child,  who 
ought  not  to  be  returned  to  the  breast  until  after  having  been 
nourished  for  some  time  with  cows'  or  goats'  milk,  diluted  with 
a  decoction  of  oatmeal.     The  feet  must  be  kept  warm,  and  the 

♦  Duges,  loc.  cit.,  p.  42. 


ON    THE    DISEASES    OF    INFANTS.  357 

body  covered  with  flannel  applied  next  to  the  skin  ;  this  kind  of 
permanent  irritation  is  very  necessary  in  convalescence  from 
abdominal  phlegmasiae. 


CHAPTER  VI. 


ASCITES. 


It  is  not  uncommon  to  find  in  the  abdomen  of  a  child  that  has 
perished  slowly  from  chronic  phlegmasia,  a  greater  or  less  quan- 
tity of  citron-colored  serosity,  and  which  is  unaccompanied  by 
any  lesion  or  morbid  production  capable  of  revealing  the  exist- 
ence of  an  actual  inflammation  of  the  peritoneum.  The  quan- 
tity of  this  effusion  varies  from  one  to  three  and  four  ounces. 
Where  this  is  found,  the  children  are  generally  pale,  thin,  and  ex- 
tremely feeble ;  the  inferior  extremities  are  almost  always  (Ede- 
matous, and  the  digestive  passages,  although  sometimes  inflamed, 
are  usually  colorless  or  softened.  This  affection  is  more  frequent 
after  the  first  year,  but  is  sometimes  observed  in  very  young  in- 
fants. Infants  at  birth  have  been  affected  with  true  dropsy.  An 
instance  of  this  is  found  in  the  journal  of  medicine,  pharmacy, 
and  surgery  of  Professor  Roux. 

A  woman  of  Charleville,  aged  thirty  years,  having  fallen  and 
injured  herself  on  the  abdomen  during  her  pregnancy,  experi- 
enced, on  rising,  a  general  movement  about  the  lumbar  and  hy- 
pogastric regions  ;  she  was  soon  affected  with  strangury.  About 
a  month  afterwards,  labor  pains  began  to  be  felt,  but  the  labor 
was  very  difficult  on  account  of  the  great  size  of  the  bladder, 
which  it  became  necessary  to  puncture.  About  six  pints  of  fluid 
were  discharged  by  the  canula,  and  four  by  the  natural  passage  : 
she  was  delivered  of  a  dead  child.  Upon  opening  the  body, 
nearly  a  pint  of  water  was  found  in  the  abdomen,  thorax,  and 
other  parts  ;  and  the  cellular  tissue  was  the  seat  of  a  general  in- 
filtration. Every  part  of  the  child  was  well-formed,  and  there 
did  not  appear  any  disposition  to  mortification.* 

*Journal  de  Medicine,  Chirurg.  et  Pharm.,  par  A.  Roux,  t,  17.  p.  180. 


358  ON    THE    DISEASES    OF    INFANTS. 

This  case  is  interesting,  inasmuch  as  it  presents  an  instance  of 
congenital  dropsy,  and  also  with  reference  to  the  intimate  con- 
nection which  existed  between  the  strangury,  the  retention  of  a 
large  quantity  of  urine  in  the  bladder  of  the  mother,  and  the 
hydropic  affection  of  the  child.* 

In  order  to  adopt  a  rational  course  of  treatment  in  cases  of  as 
cites  of  newly  born  children,  we  ought  to  refer  directly  to  the 
causes  which  produce  it,  and  which  appear  to  continue  its  ex- 
istence. 


CHAPTER  YII. 


HERNIAS    OF    THE    ABDOMEN. 

Congenital  hernias  of  the  abdomen  may  occur  at  any  of 
the  natural  openings  in  the  abdominal  parietes,  or  they  may  be 
the  result  of  an  imperfection,  by  which  spaces  of  greater  or  less 

*  Dr.  OUivier  (of  Angers)  has  reported  a  case  of  a  species  of  congenital  dropsy,  of 
which  there  does  not  exist,  at  this  time,  another  instance.  The  serosity  was  con- 
tained in  the  cavity  of  the  gastro-coUc  epiploon.  The  following  are  the  details  of  this 
case,  which  are  recorded  in  the  Archiv.  gen.  demed.,  t.  8,  p.  383. 

"  A  woman  whose  health  had  been  invariably  good,  was  confined  at  the  eighth 
month  with  a  dead  child ;  it  was  well-formed,  possessing  all  the  characters  of  a  foetus 
whose  development  had  proceeded  with  regularity.  I  was  struck  with  the  great 
size  of  the  abdomen,  the  walls  of  which  were  so  thin  as  to  allow  of  the  transparent  fluid 
with  which  it  was  filled  to  be  perceived.  On  making  an  incision  through  the  integu- 
ments, several  spoonfuls  of  transparent  yellow  serosity  flowed  out ;  the  peritoneum  was 
white  and  without  any  trace  of  injection.  The  cavity  of  the  abdomen  was  entirely 
filled  with  a  transparent  tumor,  formed  by  the  great  omentum,  the  laminae  of  which 
were  widely  separated  by  a  yellow,  limpid,  serous  fluid  contained  in  their  folds,  in  the 
middle  of  which  floated  two  large  albuminous  flakes.  The  surface  of  the  tumor  was 
of  an  irregular  form,  caused  by  the  vessels  which  crossed  the  lamina  of  the  epiploon, 
and  forming  several  irregular'  ridges.  In  the  posterior  fold  of  the  epiploon  there  ex- 
isted a  slight  opacity ;  the  rest  of  this  membrane  was  of  usual  transparency.  The 
hiatus  of  Winslow  was  open,  and  the  small  quantity  of  fluid  enclosed  in  the  cavity  of 
the  peritoneum,  had  probably  flowed  out  by  that  opcniiig.  None  of  the  other  abdomi- 
nal organs  exhibited  any  alteration." 

Do  not  the  preceding  details  tend  to  prove  that  this  dropsy  was  the  result  of  epip- 
loitis,  without  any  participation  of  the  rest  of  the  peritoneum  in  this  circumscribed  in- 
flammation ? 


ON   THE    DISEASES    OF    INFANTS.  359 

extent  are  left,  through  which  the  organs  enclosed  in  the  abdo- 
men escape. 

Umbilical  hernia. — We  have  seen  that,  in  the  beginning  of 
the  fcEtal  existence,  the  intestinal  tube  is  almost  entirely  situated 
at  the  base  of  the  umbilical  cord,  which,  by  growing  in  breadth, 
forms  tlie  anterior  part  of  the  parietes  of  the  abdomen  ;  in  pro- 
portion as  the  child  advances  in  age,  the  base  of  the  cord  retires, 
the  intestinal  convolutions  enter  the  cavity  which  is  henceforth 
to  contain  them,  and  an  aponeurotic  ring  surrounds  and  contracts 
the  base  of  the  cord,  which  contains  at  birth  nothing  more  than 
the  urachus  and  the  umbilical  vessels.     But  if  this  part  of  the 
cord  remains  large,  and  continues  to  lodge  some  of  the  convolu- 
tions of  the  intestines,  there  is  formed  a  sort  of  round  or  conical 
pouch  or  sac,  the  summit  of  which  corresponds  with  the  implan- 
tation of  the  cord ;  the  base,  to  the  circumference  of  the  aponeuro- 
tic ring  already  spoken  of,  and  which  is  then  much  larger  than 
it  usually  is,  when  in  a  natural  state  ;  the  skin  and  cellular  tissue 
more  or  less  condensed,  together  with  the  peritoneum,  form  a 
triple  coat  to  this  hernial  sac,  where  are  usually  lodged  one  or 
more  convolutions  of  the  small  intestines.     When  a  child  pre- 
sents this  infirmity  at  birth,  care  must  be  taken,  in  tying  the  cord, 
not  to  include  the  protruding  intestine  in-  the  ligature ;  but  it 
most  often  happens  that  it  is  not  until  the  end  of  some  days  that 
the  hernia  is  first  perceived,  because  the  intestines  are  pushed  to- 
wards the  umbilicus,  escape  through  the  opening  and  project 
from  the  umbilicus,  when  they  are  distended  with  aliment,  and 
are  crowded  downward  by  the  contractions  of  the  diaphragm 
during  respiration  and  the  act  of  crying.     Thus,  although  her- 
nia may  not  have  been  very  apparent  at  birth,  still  it  is  not  the 
less  congenital,  because  the  disposition  of  parts  which  constitute 
it  existed  at  that  period.     At  other  times,  hernia  shows  itself 
fully  formed  as  soon  as  the  child  is  born. 

In  either  case  it  will  be  necessary  to  attempt  the  removal  of  the 
affection.  Two  methods  of  doing  this  are  recommended  by 
authors — ligature  and  compression. 

The  ligature  formerly  in  use,  and  described  by  Celsus,  has 
been  revived  by  Desault.  This  celebrated  surg*eon  tied  the  base 
of  the  tumor,  which,  being  thus  compressed  and  narrowed,  be- 
came the  seat  of  adhesive  inflammation,  and  in  this  manner  the 


360  ON   THE    DISEASES    OF    INFANTS. 

umbilical  opening  was  closed,  and  an  adhesion  of  the  sides  of 
the  peritoneal  sac  effected.* 

This  method,  most  successful  in  appearance  at  the  time  of  the 
operation  than  in  its  results,  has  been  disapproved  of  by  most 
modern  surgeons,  who  have  abandoned  it  from  having  found 
that  a  great  number  of  children  operated  on  by  Desault,  had  ex- 
perienced a  relapse ;  what,  therefore,  this  celebrated  surgeon 
regarded  as  a  radical  cure,  was  but  a  temporary  relief! 

Compression,  then,  is  the  method  most  generally  adopted  at 
the  present  day,  and  if  its  success  be  slower,  it  is  more  perma- 
nent. It  is  applied  by  fixing  an  appropriate  bandage  over  the 
umbilicus ;  or  we  may  find  it  only  necessary  in  young  infants, 
where  the  cord  has  fallen  off,  to  use  a  graduated  compress,  kept 
in  its  place  by  a  bandage  around  the  body ;  or,  in  order  to  main- 
tain compression,  an  elastic  belt  might  be  found  useful.  In  propor- 
tion as  the  child  advances  in  age,  the  umbilical  opening  contracts, 
as  the  intestines  acquire  too  great  a  volume  to  pass  beyond  it. 

Congenital  inguinal  hernia. — The  testicles,  in  passing  out  of 
the  abdomen  of  the  foetus  through  the  abdominal  ring,  carry 
with  them  the  peritoneum  as  a  kind  of  envelope,  at  first  partial^ 
but  afterwards  more  general,  and  which  subsequently  closes  up 
over  the  organ  so  as  to  form  a  sac,  without  any  communication 
with  the  abdomen.  But  if,  instead  of  closing,  the  sac  remains 
freely  open,  a  doubling  of  the  intestine  or  a  portion  of  the  omen- 
tum may  descend,  producing  congenital  inguinal  hernia,  in  which 
the  intestine  is  in  contact  with  the  testicle,  and  even  sometimes 
adheres  to  it. 

This  species  of  hernia  does  not  always  exist  at  the  period  of 
birth  ;  often  it  does  not  manifest  itself  until  some  time  after,  fol- 
lowing the  efforts  that  attend  painful  respiration  or  crying ;  but 
it  is  necessary  to  its  existence  that  the  child  be  born  with  the 
peculiar  disposition  of  parts  which  we  have  just  described  be- 
tween the  testicle,  tunica  vaginalis,  and  the  communication 
more  or  less  free  between  it  and  the  abdomen.  This  communi- 
cation may  exist  without  causing  hernia,  an  instance  of  which 
is  given  by  Hesslebach.t 

♦  Bichat,  (Euvres  chirurgicales  de  Desault,  t.  2,  p.  315. 
+  Richerand,  Nosographie  chirurgicale,  t.2,  p.  453. 
t  Med.  chir.,  Zeitung,  1819,  p.  110. 


ON    THE    DISEASES    OF    INFANTS.  361 

It  often  happens  that  the  testicle,  at  the  period  of  birth,  has 
not  descended  into  the  scrotum :  it  may  be  at  the  ring,  either  on 
the  point  of  passing,  or  may  have  just  passed,  forming  a  round 
tumor  of  some  hardness,  which  must  not  be  mistaken  for  a  her- 
nia. There  can  be  no  certainty  that  inguinal  hernia  exists  in 
young  infants,  until  the  testicle  has  descended  into  the  scrotum. 
Again,  we  must  be  cautious  against  mistaking  the  fold  of  intes- 
tine for  the  testicle,  and  vice  versa.  This  error  appears  to  be 
possible,  since  Pott  has  seen,  in  very  young  children,  a  portioil 
of  the  intestine  or  omentum  descend  to  the  bottom  of  the  sac, 
whilst  the  testicle' was  still  at  the  ring,  or  even  in  the  abdomen.* 

All  hernias  occurring  in  young  infants  are  not  congenital,  for 
Mr.  Lawrence  has  seen  an  ordinary  inguinal  hernia  which  be- 
came strangulated  in  a  child  of  fourteen  months.!  I  shall  not 
enter  into  all  the  anatomical  details  appertaining  to  the  history 
of  congenital  inguinal  hernias;  but  will  refer  to  those  works 
especially  devoted  to  this  subject  for  further  information. 

When  a  child  is  born  with  inguinal  hernia,  or  when  it  appears 
some  time  after  birth,  it  will  be  necessary,  in  the  first  place,  to 
reduce  it,  and  to  apply  a  temporary  bandage,  but  slightly  com- 
pressive, often  changing  it  to  prevent  the  irritation  of  the  skin  at 
a  point  which  perhaps  may  be  continually  soiled  with  alvine 
evacuations,  using  a  permanent  bandage  so  soon  as  the  age  of 
the  child  will  allow  of  its  use.  In  every  instance  we  ought  to  be 
positively  assured  that  the  testicle  is  in  the  scrotum,  before  using 
compression  at  the  ring,  and  that  the  fluid  which  the  sac  some- 
times contains  is  returned  to  the  abdomen. 

If  the  hernia  become  inflamed,  of  which  we  may  satisfy  our- 
selves by  the  tumefaction  and  pain,  it  will  be  necessary  to  apply  a 
few  leeches,  and  a  poultice,  using  a  warm  bath  at  the  same  time. 

From  what  has  been  said  in  relation  to  the  formation  of  ingui- 
nal hernia,  evidently  caused  by  the  descent  of  the  testicle  into  the 
scrotum,  we  might  conclude  that  congenital  hernia  is  only  to  be 
found  in  boys ;  yet  I  once  saw  it  in  a  little  girl.  Before  explain- 
ing how  this  hernia  is  caused,  I  will  relate  the  case. 

CASE  LVII. — Congenital  inguinal  hernia,  formed  by  the  ovarii 
urn. — Josephine  Romer,  aged  seventeen  days,  entered  the  infirmary 

*  Cooper's  Surgical  Diet.  t  Lawrence  on  ruptures,  p.  G5. 

46 


362  ON    THE    DISEASES    OP    INFANTS. 

on  the  12th  of  September.  She  was  strong,  and  appeared  to  possess 
a  good  constitution ;  the  abdomen  was  a  little  tense ;  there  existed 
at  the  left  inguinal  region  a  round  tumor  about  the  size  of  a  filbert, 
somewhat  hard  to  the  touch,  and  could  neither  be  returned  to  the  ab- 
domen nor  diminished  by  pressure,  nor  did  its  size  augment  on  the 
crying  of  the  child.  It  was  directed  obliquely  towards  the  labium 
of  the  same  side,  but  did  not  quite  reach  it.  When  the  situation  of 
the  tumor  was  considered,  the  conviction  could  hardly  be  resisted 
tjiat  it  was  a  congenital  inguinal  hernia,  yet  the  sex  of  the  child  for- 
bid this  supposition.  Our  judgment  was  therefore  suspended  until, 
at  the  end  of  twenty-six  days,  the  death  of  the  child  from  pneumo- 
nia enabled  us  to  ascertain,  by  dissection,  the  nature  of  this  tumor. 

The  body  was  much  reduced  by  marasmus  ;  there  existed  an  evi- 
dent injection  of  the  intestinal  tube  ;  a  slight  inflammation  of  the  fol- 
licles of  the  large  intestines,  and  a  well-marked  hepatization  of  the 
right  lung  at  its  inferior  lobe  and  posterior  border. 

The  hernial  tumor  was  formed  by  the  left  ovarium,  which  had  de- 
scended through  the  inguinal  canal  and  ring,  which  was  much  larger 
than  is  usual  to  find  it  in  girls.  The  uterus,  drawn  by  the  round 
ligament,  and  by  the  ovarium  which  formed  the  hernia,  had  deviated 
from  its  natural  position,  and  was  inclined  towards  the  left  side  of  the 
bladder.  The  left  kidney,  instead  of  being  found  on  the  level  with 
the  other,  was  drawn  downwards  by  the  cellular  tissue,  with  which 
it  was  enveloped,  and  also  by  a  fold  of  the  peritoneum,  which  was 
intimately  connected  with  the  orifice  of  the  sac ;  the  renal  artery 
and  vein  had  also  yielded  to  this  traction,  and  were  elongated  and 
narrowed  at  the  same  time  ;  and  lastly,  the  ovarium  and  the  fimbriat- 
ed extremity  of  the  Fallopian  tube,  a  little  reddened  and  tumefied, 
were  lodged  at  the  bottom  of  the  sac  formed  by  a  prolongation  of 
the  peritoneum,  with  which  cavity  it  communicated.  There  were  no 
convolutions  of  the  intestines  adhering  to  the  surrounding  parts, 
and  the  ovarium  of  the  opposite  side  was  in  its  usual  situation. 

Upon  carefully  examining  the  round  ligament  of  the  uterus  on  the 
side  on  which  the  hernia  existed,  I  found  it  much  shorter  than  that 
of  the  opposite  side,  and  that  it  terminated  in  the  labium  by  an  apo- 
neurotic expansion,  in  place  of  losing  itself  in  loose  filaments,  as  is 
usually  observed  to  be  the  case ;  from  which  it  would  seem  that  the 
ligament,  shorter  and  more  firmly  fixed  to  the  labium,  had,  in  the 
first  place,  caused  the  deviation  of  the  uterus,  and  afterwards  drew 
with  it  the  ovarium  through  the  inguinal  ring.  It  followed  from  this 
abnormal  adhesion,  that  all  the  moveable  parts  on  the  left  side  of  the 


ON   THE    DISEASES    OF    INFANTS.  363 

abdomen  which  had  connection  of  continuity  or  of  contiguity  with 
the  hernia,  were  drawn  to  the  side  of  the  hernia,  for  they  were  not 
separated  from  each  other,  nor  did  they  follow  the  abdomen  in  its 
enlargement  during  the  development  of  the  foetus  in  the  uterus.  I 
will  return  to  this  subject  when  considering  the  diseases  of  the 
genital  organs. 

I  have  said  that  other  abdominal  hernias  may  result  from  a 
default  in  the  development  of  the  walls  of  this  cavity.  It  is  near 
the  umbilicus  and  on  the  median  line  that  it  is  more  often  ob- 
served. The  skin  at  the  umbilicus  is  sometimes  wanting,  and 
the  base  of  the  cord  alone  forms  the  exterior  of  the  sac,  enclosing 
the  intestines  that  had  passed  through  an  opening  at  the  umbili- 
cus. Sometimes  it  happens  that  the  covering  is  so  thin,  that  the 
intestine  forming  the  hernia  can  be  seen  through  the  tissue.  Mr. 
Hey,  in  a  similar  case,  had  recourse  to  the  following  means  to 
cure  this  infirmity :  havmg  reduced  the  intestines,  he  confided 
to  an  assistant  the  compressing  of  the  cord  close  to  the  abdomen 
to  prevent  the  return  of  the  intestines  into  the  hernial  sac.  "  I 
procured,"  says  he,  "  some  plaster  spread  on  leather  cut  in  circu- 
lar pieces,  and  laid  upon  one  another  in  a  conical  form.  This 
compress  I  placed  upon  the  navel,  after  I  had  brought  the  skin  on 
each  side  of  the  aperture  into  contact,  and  laid  one  of  the  lips  a 
little  over  the  other.  I  then  put  round  the  child's  abdomen  a 
linen  belt,  and  placed  upon  the  navel  a  thick  circular  quilted 
pad.  This  bandage  kept  the  intestine  securely  within  the  abdo- 
men, and  was  renewed  occasionally.  The  funis  was  separated 
about  a  week  after  birth  ;  and  at  the  expiration  of  a  fortnight 
from  that  time,  the  aperture  at  the  navel  was  so  far  contracted 
that  the  crying  of  the  child  did  not  cause  the  least  protrusion."* 

A  much  greater  imperforation  in  the  parietes  of  the  abdomen 
may  occasion  considerable  displacement  of  the  viscera  contained 
in  this  cavity.  Mellet  has  reported  a  case  in  the  Yandermonde 
Journal,  of  a  woman  who  was  delivered  of  a  child  where  the  in- 
testines and  the  whole  of  the  mesentery  had  escaped  from  the 
abdomen  through  a  round  opening,  about  an  inch  and  a  half  in 
diameter,  situated  in  the  umbilical  region,  about  two  lines  from 
the  navel. 

♦  Dictionary  of  Practical  Surgery,  by  Samuel  Cooper. 


364  ON    THE    DISEASES    OF    INFANTS. 

The  smallness  of  this  opening,  the  great  volume  which  the 
parts  presented  in  consequience  of  the  swelUng  of  the  intestines 
and  stomach,  and  the  extreme  feebleness  of  the. child,  would  not 
allow  of  any  measures  being  used  to  effect  a  reduction.  The 
child  was  sustained  by  sweetened  wine  and  water  ;  and  although 
the  intestines  appeared  to  be  strangulated  by  this  small  opening, 
the  fluids  given  it  were  observed  to  pass  even  to  the  rectum,  since 
some  hours  after  passing  the  meconium,  the  child  vomited  by 
stool  other  liquid  matters,  which  possessed  something  of  the  co- 
lor of  wine.  The  child  died  in  about  two  hours,  and  on  the  fol- 
lowing day  the  disposition  of  the  parts  were  examined,  and  the 
portion  which  escaped  from  the  opening  described,  was  found  to 
reach  even  to  the  thighs.  The  whole  of  the  stomach,  the  small 
intestines,  colon, — the  extremity  of  which,  where  it  joins  the  rec- 
tum, re-entered  the  abdomen  through  the  opening, — the  mesen- 
tery, the  left  kidney,  the  supra-renal  capsules  of  the  same  side, 
and  the  spleen,  were  found  outside  of  the  abdomen,  without  any 
membranous  envelope ;  the  peritoneum  and  the  omentum  were 
entirely  wanting.  There  was  nothing  in  the  interior  but  the 
liver,  which  was  prodigiously  enlarged,  and  the  right  kidney, 
which  occupied  its  natural  place ;  the  left  ureter  was  much 
larger  than  the  right ;  there  was  no  pancreas.* 

In  such  a  case,  I  am  of  opinion  that  the  stricture  should  be 
relieved,  and  the  viscera  gradually  and  cautiously  returned. 
The  application  of  a  bandage,  armed  with  a  pad  slightly  com- 
pressive, would  probably  assist  in  obliterating  the  opening. 

This  is  the  proper  place  for  speaking  of  those  accidental  tu- 
mors enclosing  the  fragments  of  another  foetus,  and  which  have 
been  sometimes  seen  developed  in  different  points  of  the  abdomi- 
nal cavity ;  but  the  consideration  of  this  subject  would  lead  me 
into  details  which  do  not  comport  with  the  limits  which  I  have 
prescribed  to  this  work.t 

*  Case  of  a  child  born  with  all  the  contents  of  the  abdomen  outside  of  the  cavity,  by 
M.  Mellet,  surgeon  and  accoucheur  at  Chalons,  sur.  mer.  journal  de  med.  chirurg. 
etpharm.    May,  1756. 

t  Consult  Dupuytren,  Rapport  fait  d  la  Societe  de  la  Faculte.  Reports  of  this 
Society  No.  1,  p  4.  Ad.  Lachaise,  de  la  dwplidte  monstrueuse  par  inclusion.  Paris, 
1823.  C.  P.  OUivier,  Memoire  sur  la  monstruoslte  par  inclusion,  Archives  ge- 
neral de  medecine.  t.  15  and  17. — Isid.  Geffroy  St.  Hilaire,  Hist,  des  ar.omalies  de 


ON    THE    DISEASES    OF    INFANTS.  365 


PROLAPSUS    OF    THE    RECTUM. 

Prolapsus  of  the  rectum  consists  in  an  unlining,  as  it  were,  of 
the  internal  membrane  of  this  intestine.  As  this  membrane  is 
soft,  and  only  adheres  to  the  other  membranes  by  loose  cellular 
tissue,  it  projects  externally,  and  forms  at  the  anus  a  thick  red 
ring,  which  is  sometimes  bloody  whenever  it  is  pushed  down- 
wards by  any  cause  whatever — such  as  constipation,  or  the  con- 
tinual crying  of  an  enfeebled  child,  or  when  a  large  quantity  of 
foeces  is  passed  after  an  obstinate  constipation.  It  may  also  be 
produced  by  large  stools  following  the  administration  of  a  pur- 
gative. 

I  do  not  know  on  what  reasons  Underwood  has  founded  his 
opinion  that  this  accident  is  a  symptomatic  affection  of  the  pre- 
sence of  worms  or  other  irritating  matter  in  the  intestines.  There 
really  exists  no  relation  between  these  affections. 

Immediately  on  the  protrusion  of  the  rectum,  it  will  be  neces- 
sary to  attempt  the  return  of  the  ring  formed  by  the  mucous 
membrane  ;  this  may  be  accomphshed  by  pushing  the  protruded 
part  upwards  with  the  fingers,  anointed  with  cerate  or  oil, 
taking  the  precaution  to  cause  the  ring  to  enter  first.  The  tu- 
mor thus  reduced  may  be  kept  in  its  position  by  means  of  com- 
presses wetted  with  cold  water,  and  which  may  be  retained  in 
their  place  with  a  T  bandage.  If  this  disorder  should  continue, 
it  will  be  necessary,  as  the  child  advances  in  age,  to  prevent  the 
prolapsus  by  supporting  the  circumference  of  the  anus  during  the 
efforts  at  defecation.  Aromatic  powders,  or  astringent  lotions, 
add  but  little  to  the  mechanical  means  to  which  it  is  necessary 
to  resort  in  order  to  support  the  rectum. 

C organisation  chez  Vhommes  et  les  animaux,  1833,  in  8vo.  fig. — Serres,  Rescher- 
ches  d'anatomie  transcendante  et  .pathologique  ;  theorie  des  formations  organiques 
appliqute  a  Vanatomie  de  la  duplicite  monstrueuse,     Paris,  1832. 


366  ON   THE    DISEASES   OF   INFANTS. 

CHAPTER    YII. 

DISEASES    OF    THE    RESPIRATORY    APPARATUS. 

In  the  respiratory  apparatus  is  comprehended  the  nasal  fossae, 
larynx,  trachea,  and  lungs. 

Section  I. 

DISEASES    OF    THE    NOSE     AND    NASAL    FOSSAE. 

It  may  create  some  surprise  to  see  the  nasal  fossae  classed  with 
the  organs  of  the  respiratory  apparatus.  In  man,  the  nose  and 
the  nasal  fossae  are  but  an  accessary  part,  and  one  not  immedi- 
ately dependent  on  the  respiratory  system ;  they  are  especially 
destined  to  olfaction.  In  some  animals,  and  particularly  among 
fishes,  the  nasal  fossae  are  altogether  separated  from  the  respira- 
tory passages  ;  but  this  is  not  the  case  with  an  infant  at  birth ; 
it  respires  very  little  by  the  mouth,  which  is  almost  always  shut, 
and  while  sucking,  it  is  essentially  necessary  that  the  air  pene- 
trate the  lungs  through  the  nasal  fossae,  since  the  buccal  cavity, 
applied  to  the  nipple,  is  continually  filled  with  milk.  Besides, 
without  this  it  would  be  impossible  to  prolong  the  act  of  sucking 
for  any  length  of  time. 

The  importance  of  the  functions  which  the  nasal  fossae  fulfil, 
as  an  organ  subsidiary  to  the  respiratory  apparatus,  is  also  de- 
monstrated by  the  seriousness  of  the  diseases  which  are  developed 
in  them.  Thus,  it  appears  of  more  importance  to  consider  the 
nasal  fossae  rather  as  an  organ  of  respiration  than  an  organ  of 
olfaction  in  an  infant,  who  cannot  enjoy  the  sense  of  smell. 
These  considerations  will  suffice  without  doubt  for  our  motive 
in  placing  the  diseases  of  the  nose  and  nasal  fossae  among  those 
of  the  respiratory  organs. 

Development  and  congenital  malformations. — During  the 
first  period  of  intra-uterine  life,  the  nose  does  not  exist ;  the  nasal 
fossae,  which  at  first  communicate  with  the  mouth,  separate  from, 
it  gradually  by  the  approximation  and  union  of  the  two  lateral 


ON    THE    DISEASES    OF    INFANTS.  367 

parts  of  the  palatine  arch.  At  six  weeks  or  two  months,  two 
small  holes  situated  by  the  side  of  each  other  appear  above  the 
mouth ;  these  are  the  commencement  of  the  opening  of  the  nos- 
trils ;  very  soon  two  slight  projections  arise  above  these  openings ; 
they  are  the  first  rudiments  of  the  alae  of  the  nose,  which  arise 
by  degrees,  but  are  very  incomplete ;  for  during  the  whole 
of  the  intra-uterine  •  life,  it  continues  quite  small  and  obtuse. 
Whilst  the  progress  of  the  formation  of  the  nose  is  in  operation, 
the  nasal  fossae  enlarge,  particularly  in  height ;  they  are  also  a 
little  spread  at  the  bottom,  but  continue  very  narrow  at  the 
superior  part.  The  sinuses  and  cornua  are  formed  without 
leaving  any  thing  but  a  very  narrow  space  between  them ;  the 
mucous  membrane  with  which  they  are  covered  is  very  red  and 
thick  in  the  latter  period  of  foBtal  life,  and  it  exhibits  the  same 
characters  at  birth.  The  frontal  and  maxillary  sinuses  do  not 
as  yet  exist ;  they  are  not  formed  until  a  more  advanced  period. 

We  have  seen  that  the  holes  of  the  nose  do  not  exist  at  first; 
their  development  may  be  impeded  or  suspended,  and  the  child 
be  born  with  an  entire  absence  of  the  nose,  or  with  a  considerable 
flatness  of  this  organ,  which  preserves  through  life  the  traces  of 
this  primitive  formation ;  but  its  complete  absence  usually  de- 
pends on  the  absence  of  the  ethmoid  bone ;  the  two  eyes,  united 
together,  are  lodged  in  a  cavity  commonly  situated  at  the  place 
of  the  nose.  M.  de  Larue  has  given  in  the  Vandermonde  Journal, 
the  case  of  a  monster,  of  the  cyclops  order,  which  presented  the 
following  appearance :  the  size  of  the  head,  he  observes,  was 
proportioned  to  that  of  the  body ;  the  forehead  was  very  large, 
and  occupied  three  fourths  of  the  face ;  not  the  slightest  trace  of 
a  nose  could  be  found  ;  there  appeared  to  be  nothing  more  than 
an  oval  opening,  situated  horizontally  at  the  place  where  the 
point  of  the  nose  should  have  been,  six  lines  above  the  superior 
alveolar  process.  Neither  the  cerebrum  nor  cerebellum  exhibited 
any  thing  extraordinary ;  there  was  no  olfactory  nerve,  and  al- 
though the  bed  of  these  nerves  existed,  there  was  no  ethmoid 
bone  nor  cribriform  plate.* 

Sometimes  there  is  found  in  place  of  a  nose  a  kind  of  prolon- 

*  Observation  sur  un  monstre  cyclope,  by  M.  de  Larue,  surgeon  and  demonstrator 
of  anatomy  at  Rennes,  Journal  de  med.  chir.  and  pharm.,  t.  7,  p.  278. 


368  ON   THE    DISEASES    OF    INFANTS. 

gation,  produced  without  doubt  by  the  remains  of  the  skin  which 
ought  to  cover  the  nasal  eminence.  The  nose  may  be  prolonged 
in  such  a  manner  as  to  form  a  real  proboscis  descending  below 
the  mouth.  I  have  seen  an  instance  of  this  deformity  preserved 
by  Dr.  Gamier  of  Angers.  Without  being  thus  prolonged,  the 
nasal  eminence  instead  of  being  short  and  depressed,  as  is  the 
case  in  infants  at  birth,  already  possessed  the  full  form  of  an 
adult's  nose,  and  bore  a  close  resemblance  to  it :  this  premature 
development  ought  to  be  regarded  as  a  species  of  deformity.  I 
have  also  seen  an  infant  at  birth,  where  the  nose  possessed  the 
shape  known  by  the  name  of  aquiline'  Lastly,  there  have  been 
examples  of  bifid  noses,* — or  without  being  completely  double, 
showing  in  a  very  marked  manner,  the  median  line  which  sepa- 
rates the  two  lateral  parts  of  this  organ.f 

Diseases  developed  after  birth. — In  an  infant  at  birth,  the 
pituitary  membrane  is  always  very  red,  and  very  much  engorged, 
and  it  possesses  besides  great  irritability  ;  for  we  often  see  chil- 
dren sneeze  at  birth,  immediately  on  the  air  coming  in  contact 
with  this  part.    The  membrane  also  secretes  an  abundant  mucus 

*  The  complete  separation  of  the  two  portions  of  the  nose  may  also  be  produced  by 
the  formation  of  tumors  in  the  nasal  fossae,  which  date  their  existence  from  the  earliest 
period  of  the  formation  of  the  embryo.  Dr.  Rosata  Dimidry  has  given  a  very  remark- 
able instance  of  this.  On  the  7th  of  September,  1830,  a  young  woman,  of  the  com- 
mune de  Vaglie,  canton  of  Brindisi,  in  the  province  of  Lecce,  was  deUvered  of  a  girl, 
who  exhibited  a  large-sized  fleshy  prolongation,  extending  from  the  nose  over  and 
below  the  mouth.  An  attentive  examination  satisfied  Dr.  Dimidry,  that  the  nose  of 
this  child  was  bifid,  being  divided  at  the  base  so  that  the  two  portions  were  separated, 
and  between  them  projected  a  tumor  of  the  size  of  a  goose's  egg,  closely  adhering  to  the 
entire  circumference  of  the  nasal  opening  and  the  upper  lip,  before  which  it  descended ; 
afterwards  becoming  free,  it  was  extended  eveii  to  the  lower  lip,  thus  almost  com- 
pletely closing  the  opening  of  the  mouth.  At  the  upper  part  of  this  abnormal  produc- 
tion appeared  a  nipple-like  protuberance,  and  one  of  similar  shape  and  appearance  at 
the  inferior  part  contiguous  to  the  lower  lip. 

Dr.  Dimidry  ascertained  that  this  tumor  interfered  with  respiration,  by  the  complete 
closure  of  the  nostrils,  and  the  almost  entire  closure  of  the  buccal  opening ;  and  not 
doubting  but  a  complete  asphyxia  would  ensue,  which  would  be  quickly  mortal,  he 
decided  to  remove  the  tumor  by  one  stroke  of  the  knife.  The  dissection  of  this  tumor 
proved  it  to  be  enveloped  by  a  prolongation  of  skin,  and  that  its  tissue  had  the  granu- 
lated appearance  of  a  glandular  body. 

Notwithstanding  all  the  means  employed  to  sustain  this  child,  it  could  not  be  accom- 
plished, and  it  died  four  hours  after  the  operation.  {Anali  di  med.  et  chir.  di  Napolii 
Septem.  1830.) 

t  Victor  Laroche,  Dissert,  inaug.,  p.  50. 


ON   THE    DISEASES    OF    INFANTS.  369 

at  a  very  early  period,  and  it  flows  constantly  from  the  nose  in 
some  children.  Thus,  the  sanguineous  congestion,  redness,  irri- 
tability, and  the  abundant  secretion  of  the  pituitary  membrane 
in  young  infants,  demonstrate  the  great  disposition  in  this  mem- 
brane to  inflame,  and  explain  the  frequency  of  coryza  in  new- 
born children.  This  disease  has  attracted  the  attention  of  pa- 
thologists ;  and  I  will  endeavor  to  give  an  account  of  the  afiec- 
tion. 

It  may  be  simple  or  complicated,  with  a  more  or  less  rapid 
formation  of  a  membranous  concretion  throughout  the  whole 
extent  of  the  nasal  fossae. 

Shnple  Coryza, — The  action  of  cold,  humid  air,  the  chilliness 
of  the  extremities,  v/hen  wetted  with  the  urine,  in  those  infants 
where  there  is  a  great  negligence  in  changing  their  clothes,  ex- 
posure to  a  strong  fire,  and  particularly  to  the  light  and  heat  of 
the  solar  rays,  are  the  usual  causes  of  this  affection  in  young 
infants.  When  children  are  taken  out  for  the  benefit  of  the  air 
on  the  return  of  spring,  it  is  almost  always  observed  that  they 
sneeze  and  experience  a  discharge  from  the  nose,  and  the 
promptitude  with  which  insolation  acts  on  the  pituitary  mem- 
brane is  greater  at  this  season,  because  during  the  winter  they 
are  less  accustomed  to  the  impression  of  the  sun.  This  is  per- 
haps the  reason  why  people  regard  the  sun  in  the  month  of  May 
as  unhealthy.  From  whatever  cause  it  may  arise,  whenever  the 
pituitary  membrane  of  infants  is  inflamed,  it  presents  the  follow 
ing  symptoms. 

Frequent  sneezing  is  the  first  sign  of  this  affection.  Soon 
after,  mucosity  flows  from  the  nostrils,  at  first  ropy  and  clear, 
afterwards  yellow,  and  lastly,  purulent.  The  child,  who  almost 
always  sleeps  with  its  mouth  closed,  cannot  now  sleep  without 
keeping  it  open :  the  respiration  is  noisy,  and  instead  of  the  usual 
rale,  a  whistling  sound  occurs  in  the  nasal  fossae.  This  sound 
becomes  greater,  and  the  difficulty  of  respiration  increases  in 
proportion  as  the  nasal  mucosities  become  thicker  and  more 
abundant.  This  discharge  dries  at  the  orifice  of  the  nostrils, 
which  are  more  or  less  closed,  and  thereby  prevents  the  entrance 
of  air  :  the  restlessness,  cries,  and  the  physiognomy  of  the  child 
express  the  distress  it  suffers.     If  at  this  time  it  is  placed  at  the 

breast,  its  anxiety  and  the  sufl^ocation  increase,  it  leaves  the  nip- 

47 


370  ON   THE    DISEASES    OF    INFANTS. 

pie  because  unable  to  exercise  suction,  as  it  can  only  respire  by 
the  mouth  J  which  is  filled  with  the  nipple  and  the  milk  that 
flows  from  it ;  and  being  thus  in  a  continual  state  of  agitation 
from  the  sense  of  hunger,  and  the  impossibility  of  satisfying  it, 
soon  becomes  exhausted  by  fatigue,  pain,  and  inanition^  and 
quickly  perishes,  even  before  arriving  at  an  advanced  stage  of 
marasmus.  The  progress  of  symptoms  is  sometimes  very  rapid, 
and  a  young  infant  may  die  in  three  or  four  days,  from  this  dis- 
ease ;  and  on  this  account  it  is  justly  regarded  as  of  a  most 
serious  character  in  infants.  On  the  other  hand,  it  is  not  to  be 
always  looked  upon  as  so  serious  ;  for  the  danger  of  the  disease 
is  always  proportionate  to  the  degree  of  tumefaction  of  the  pitui- 
tary membrane,  and  to  the  abundance,  and  especially  the  consis- 
tence of  the  mucosities  secreted  by  the  inflamed  membrane. 
When  therefore  the  inflammation  is  slight,  the  nasal  mucosities 
are  only  a  little  more  abundant,  clear,  and  ropy  than  in  the  na- 
tural state,  and  the  inconvenience  of  respiration  is  but  slight. 
In  general,  coryza  is  not  a  dangerous  disease  when  the  infant 
can  suck;  the  danger  begins  with  the  difficulty  of  respiration, 
and  the  inability  to  suck ;  and  all  other  things  being  equal,  it  is 
more  serious  in  proportion  to  the  tender  age  of  the  child. 

Coryza  'with  pellicular  concretions. — Inflammation  of  the  pitu 
itary  membrane  sometimes  gives  rise  to  the  formation  of  pseudo- 
membranous concretions  which  cover  the  surface  of  the  nasal 
fossae.  In  forty  children  affected  with  coryza  of  greater  or  less 
intensity,  that  were  treated  at  the  infirmary  of  the  Institution  of 
the  En  fans  Trouves,  there  were  five  with  the  false  membranes 
covering  the  sinus  and  the  cornua,  and  adhering  more  or  less 
closely  to  the  pituitary  membrane,  which  was  of  a  vivid  red, 
thick,  and  very  friable.  The  formation  of  these  false  membranes 
had  been  preceded  by  all  the  symptoms  peculiar  to  coryza,  they 
were  covered  with  thick  mucosities,  in  the  midst  of  which  ap- 
peared either  the  remains,  or  the  pseudo-membranous  rudiments. 
These  children  had  sunk  very  quickly  under  the  disease,  and  in 
only  one  of  them  was  it  possible  to  make  a  diagnosis  of  the  pre- 
sence of  the  membranous  concretion  in  the  nasal  fossae,  for  the 
others  presented  nothing  more  than  the  usual  signs  of  a  very 
intense  inflammation  of  these  parts.  The  following  is  the  history 
of  this  remarkable  case. 


ON   THE    DISEASES    OF    INFANTS.  371 

CASE  LVIII; — Coryza^  with  pseudo-memhranous  concretion. — 
Marie  Eseril,  aged  six  days,  entered  the  infirmary  on  the  18th  of 
May.  She  was  small,  the  integuments  were  vermilion,  pulse  natu- 
ral, abdomen  a  little  tender ;  the  dejections  were  green  and  very 
abundant.  (Gum  syrup,  rice,  emollient  cataplasm  to  the  abdomen^ 
milk  and  ivater.)  Same  condition  to  the  twenty-first,  when  it  was 
perceived  that  the  child  sneezed  frequently,  and  that  she  swallowed 
with  difficulty  the  milk  that  was  given  her  with  a  spoon  ;  the  face 
was  pale,  the  limbs  were  not  more  oBdematus  ;  and  there  supervened 
a  slight  ophthalmia,  and  frequent  vomitings  of  undigested  milk.  To- 
wards night  there  occurred  an  abundant  flow  of  ropy  mucosity  from 
the  nostrils.  On  the  twenty-second  and  twenty-third,  same  condi- 
tion. On  the  twenty-fourth,  the  respiration  was  much  more  difficult, 
and  the  child  slept  with  her  mouth  open  ;  the  forehead  was  wrinkled, 
the  alas- of  the  nose  drawn  outward,  the  restlessness,  anxiety,  and 
frequent  cries,  which  the  feebleness  of  the  child,  however,  would  not 
allow^  of.  their  being  prolonged,  all  led  to  the  belief  that  there  exist- 
ed an  obstacle  to  the  free  passage  of  the  air  in  some  point  of  the  air 
passages.  {Same  treatment.)  On  the  twenty-fifth,  infiltration  and 
paleness  of  the  face,  continuation  of  the  .diarrhoea  and  vomiting, 
nasal  respiration  very  noisy,  accompanied,  when  the  child  cried, 
with  a  sudden  snorting,  which  terminated  the  respiratory  move- 
ment. M.  Baron  was  of  opinion  that  the  coryza,  which,  until  then, 
had  produced  an  abundant  secretion  of  mucosity,  had  become  com- 
plicated with  the  formation  of  a  membranous  concretion.  This  state 
continued  until  the  twenty-ninth  ;  the  child  fell  into  a  state  of  com- 
plete marasmus,  the  nasal  respiration  was  conducted  with  less  noise, 
but  the  mucosities,  puriform  and  green,  flowed  from  the  nose  in  great 
quantities.  On  the  thirty -first,  the  nasal  sound  returned ;  vomiting 
of  mucus  matters  occurred  every  moment,  and  the  child,  almost  un- 
able to  respire,  and  reduced  to  a  state  of  great  feebleness,  expired 
at  night. 

Upon  opening  the  body,  the  mouth  was  found  healthy,  and  the 
stomach  without  any  mark  of  disease;  two  thirds  of  the  small  in- 
testines healthy ;  but  there  existed  in  the  ileo-csecal  region  a  very 
large  red  patch,  with  tumefaction  and  friability  of  the  mucous  tissue ; 
the  ileo-caecal  valve  was  so  tumefied  as  only  to  admit  the  stylet  of  a 
female  catheter ;  the  large  intestines  were  perfectly  healthy ;  the 
liver  was  pale.  In  the  nasal  fossae  was  found  a  white  pseudo-mem- 
branous concretion,  a  little  projecting  by  the  blood  exhaled  on  its 
surface.     It  commenced  at  the  superior  part  of  the  glottis,  and  in- 


272  ON   THE    DISEASES    OF    INFANTS. 

stead  of  extending  to  the  trachea,  spread  towards  the  sinus  and  cor- 
nua  of  the  nose,  which  it  covered  closely  and  solidly.  The  mucous 
membrane  beneath  it  was  much  tumefied  and  of  a  vivid  red,  and  was 
even  bloody  in  certain  places.  The  right  lung  was  gorged  with  blood 
at  its  posterior  border  ;  the  brain  was  healthy. 

It  is  evident  that  this  child  died  from  a  coryza,  which,  at  first, 
simple,  and  attended  only  with  an  increase  of  a  very  abundant 
secretion,  was  finally  complicated  with  the  formation  of  a  pel- 
licular concretion,  and  that  this  pellicle,  by  obstructing*  the  pas- 
sage of  air,  gave  rise  to  all  the  symptoms  which  had  been  ob- 
served. It  is  probable  that  the  abundant  vomiting  was  owing  to 
an  obstruction  at  the  ileo-csecal  valve^  since  there  was  neither 
oesophagitis  nor  gastritis. 

Coryza  may  assume  a  chronic  character,  and  cause  the  death 
of  the  patient  by  the  disorganization  which  ensues.  This  was 
the  case  in  the  followinsf  instance  : 

CASE  LIX. — Chronic  coryza,  inflammatory  softening  of  the 
pituitary  membrane. — Paul  Galon,  aged  17  months,  had  been  wean- 
ed for  some  time,  entered  the  infirmary  on  the  21st  of  August;  he 
was  pale,  although  he  possessed  considerable  strength  ;  the  skin  was 
hot,  the  pulse  natural,  the  nasal  respiration  was  extremely  difficult, 
the  conjunctivae  were  slightly  injected.  {Gummed  mar shm allows, 
pedeluvium,  milk  and  water.)  During  the  month  of  March  he  pre- 
sented no  other  symptom  than  that  of  an  abundant  mucous  discharge 
from  the  nose,  a  very  difficult  respiration,  and  a  great  tendency  to 
drowsiness  ;  the  pulse  in  general  was  small  and  slow,  yet  it  became 
more  frequent  towards  night.  (Four  leeches  to  the  mastoidean  re- 
gion and  a  Mister  to  the  neck.)  This  treatment  produced  ameliora- 
tion of  symptoms,  and  the  respiration  became  better.  On  the  3d  of 
April  the  drowsiness  returned  ;  the  pulse  was  frequent  and  small ; 
paleness  universal ;  skin  dry ;  abdomen  tense  ;  respiration  difficult, 
with  an  abundant  flow  of  mucus  from  the  nostrils,  and  vomiting 
(Four  leeches  to  the  epigastrium,  cataplasm  to  the  abdomen,  diet.) 
On  the  4th  of  April  the  skin  was  cooler,  the  mouth  continued  dry ; 
there  was  no  vomiting,  and  the  pulse  less  frequent.  On  the  6th  of 
April  there  was  a  complete  disappearance  of  the  gastric  symptoms ; 
there  existed  an  abundant  flow  of  nasal  mucosity,  and  the  passage  of 
air  through  the  nasal  fossae  appeared  to  be  difficult ;  the  upper  lip 
was  (Edematous.     From  this  time  to  the  fifteenth,  the  same  state  con- 


ON   THE    DISEASES    OF    INFANTS.  373 

tinued  ;  the  child  did  not  waste  away  ;  the  nose  and  upper  lip  were 
continually  moistened  with  mucosity,  which  was  always  white  and 
ropy,  like  the  white  of  an  egg.  During  the  month  of  May  the  child 
remained  much  in  the  same  state  ;  but  on  the  2d  of  June  a  nettle- 
rash  made  its  appearance,  accompanied  with  a  little  fever,  which, 
however,  disappeared  at  the  end  of  two  days.  (Gummed  barley- 
water,  milk  and  water,,  diet.)  There  was  a  slight  melioration  of 
symptoms,  but  the  coryza  continued,  and  it  was  for  this  affection 
alone  that  the  child  remained  in  the  infirmary.  The  remainder  of 
this  month  and  the  commencement  of  July  passed  without  any  thing 
remarkable  occurring ;  but  in  the  night  of  the  fifteenth,  the  respira- 
tion became  difficult,  fever  arose,  and  a  large  quantity  of  mucosity 
flowed  from  the  nose  and  mouth.  (Sweetened  decoction  of  marsh- 
mallows,  diet.)  The  debilitated  condition  of  this  child  would  not 
allow  of  farther  depletion.  On  the  20th  of  July  the  same  state 
continued,  general  paleness,  hectic  fever,  characterized  by  the  small- 
ness  and  frequency  of  the  pulse,  and  a  burning  heat  of  the  skin  ;  the 
exacerbation  occurring  every  evening ;  marasmus  made  rapid  pro- 
gress ;  still  there  was  no  diarrhoea  nor  vomiting  ;  the  nasal  mucosity 
was  very  thick  and  abundant.  (A  linctus  with  a  grain  of  Kermes 
mineral,  blister  between  the  shoulders.)  But  slight  improvement 
of  symptoms  ensued  ;  the  child  sunk  and  wasted  from  day  to  day  ; 
the  respiration  was  noisy,  yet  the  thorax,  which,  during  the  course 
of  the  disease,  was  frequently  percussed,  did  not  yield  a  dull  sound. 
On  the  10th  of  August,  great  oppression  supervened,  and  continually 
increased,  until  a  considerable  flow  of  mucosity  occurred  from  the 
nose,  the  discharge  of  which  was  accelerated  by  sneezing.  On  the 
fifteenth,  this  discharge  of  mucus  from  the  nose  ceased,  and  the 
child  rallied  a  little  ;  he  was  extremely  emaciated,  yet  was  not  affect- 
ed with  any  disorder  of  the  bowels.  EmolUent  drinks,  mucilages, 
and  milk  and  water,  formed  the  treatment  at  this  time,  care  being 
taken  not  to  prescribe  any  nourishment  but  that  of  the  lightest  kind  ; 
but  the  nurse  having  charge  of  the  ward  thinking  that  a  dififerent 
diet  would  restore  strength  to  the  child,  secretly  gave  him  fat 
soups  and  broths.  On  the  twenty-fifth  of  August,  during  a  violent 
fit  of  crying,  one  of  the  servants,  believing  it  to  be  an  expression  of 
hunger,  took  the  child  up  and  fed  him;  he  immediately  showed 
symptoms  of  suflTocation  and  died  in  her  arms. 

On  opening  the  body  the  next  day,  the  mouth  was  found  healthy, 
the  oesophagus  pale,  the  stomach  very  much  distended  and  filled  with 
panado ;  the  mucous  membrane  of  this  organ  was  very  soft  and  red  ; 


374  ON    THE    DISEASES    OF    INFANTS. 

the  mesenteric  ganglia  were  tumefied  and  red,  and  the  mucous  mem- 
brane of  the  duodenum  covered  with  red  striae ;  the  small  intestines 
were  healthy,  but  were  very  much  distended  with  gas ;  the  lungs 
were  healthy,  but  there  existed  cellular  adhesions  between  the  two 
pleurae.  The  two  lateral  ventricles  of  the  brain  contained  an  abun- 
dant serosity ;  the  mucous  membrane  of  the  nasal  fossae  was  very 
red,  tumefied,  and  soft ;  the  larynx  and  bronchiae  were  healthy. 

I  have  been,  in  the  disease  of  this  child,  very  minute,  because 
it  appeared  to  me  interesting  to  report  all  the  circumstances  of 
the  progress  of  chronic  coryza ;  at  the  termination  of  which,  the 
pituitary  membrane  had  experienced  the  disorganization  which 
a  long  continued  inflammation  usually  produces  on  mucous 
membranes.  We  ought  also  to  remark  the  cerebral  and  gastro- 
intestinal.complications,  the  state  of  marasmus  to  which  the  pa- 
tient was  reduced,  and  the  fatal  effect  of  an  abuse  of  regimen, 
administered  by  those  who  had  the  care  of  this  child,  and  who 
were  imbued  with  those  prejudices  which  induce  people  to  give 
to  the. sick,  and  particularly  to  children,  a  large  quantity  of  food 
to  strengthen  them. 

The  most  common  complications  of  coryza  in  young  infants, 
are  cerebrial  affections.  From  the  proximity  of  the  inflamma- 
tion to  the  brain,  an  irritation  is  transmitted  to  that  organ,  from 
which  results  acute  hydrocephalus,  as  we  have  seen  was  the  case 
in  the  preceding  instance,  or  accidents  not  less  fatal ;  it  is  there- 
fore not  unusual  to  find  children  experience,  in  the  course  of  this 
disease,  a  drowsiness  and  prostration,  and  even  sometimes  con- 
vulsions, which  are  evident  signs  of  cerebral  irritation. 

The  treatment  to  be  adopted  in  this  disease  must  vary  accord- 
ing to  the  age  of  the  child  ;  in  young  infants  that  are  sucking,  it 
will  be  necessary  to  suspend  alimentation  by  the  breast,  on  ac- 
count of  the  great  pain  they  experience  while  sucking,  and  the 
difficulty  of  respiration  which  attends  the  action,  thereby  increas- 
ing the  danger  of  the  symptoms  attending  inflammation  of  the 
nasal  fossae.  Besides,  children  in  this  case  suck  so  badly  that 
the  quantity  of  milk  they  take  is  almost  insufficient  to  nourish 
them,  and  they  are  exposed  to  the  hazard  of  perishing  of  languor 
or  hunger.  Drinks  ought  to  be  given  with  great  caution,  and 
they  ought  to  be  fed  with  a  spoon  with  cows'  or  goats'  milk,  di 


ON   THE    DISEASES    OF    INFANTS.  375 

luted  with  groat  water.  If  deglutition  appear  to  be  very  diffi- 
cult, we  must  have  recourse  to  nutritive  injections.  There  is  no 
advantage  in  directing  the  vapor  of  a  decoction  of  emollients  to- 
wards the  nasal  fossa?  of  young  infants,  for  the  air  passages  are 
so  narrow  that  the  momentary  swelling  which  it  occasions,  will 
only  increase  the  difficulty  of  respiration.  The  principal  means  to 
be  employed  in  the  treatment  of  coryza  in  young  infants,  are  the 
removal  from  the  causes  which  may  produce  it,  laxative  drinks, 
such  as  a  decoction  of  prunes,  or  even  the  administration  of  a 
saline  purgative,  or  calomel  in  a  dose  of  two  or  four  grains,  in 
order  to  establish  a  revulsion  on  the  intestinal  tube,  and  by  the 
application  of  a  blister  either  to  the  neck  or  to  one  of  the  arms. 
If  any  cerebral  complication  should  arise,  it  must  be  met  with 
appropriate  means.  If,  after  having  combatted  the  inflammation 
in  the  usual  manner,  there  should  be  formed  any  pellicular  con- 
cretions in  the  nasal  fossas,  it  would  be  proper  to  have  recourse 
to  some  of  the  extraordinary  measures  which  are  recommended 
in  croup.  We  might,  for  example,  blow  gently  some  fine  calo- 
mel, or  a  mixture  of  sugar  and  alum  finely  powdered,  into  the 
nostrils.  The  introduction  of  this  powder  into  the  nose  will  be 
less  dangerous  than  into  the  trachea.  We  ought,  above  all,  so 
soon  as  there  is  perceived  any  difficulty  in  sucking,  to  remove 
the  child  from  the  breast,  because  this  difficulty  may  become,  by 
frequently  recurring,  at  last  the  cause  of  the  most  distressing  ef- 
fects, either  with  regard  to  the  nutrition  of  the  child,  or  by  the 
production  of  pulmonary  or  cerebral  congestions. 

Section  II. 

DISEASES    OF    THE    LARYNX   AND   TRACHEA. 

Development  and  congenital  wMformations. — During  foBtal 
life  the  pharynx  and  trachea  exhibit  no  series  of  progressive  phe- 
nomena that  can  be  observed  or  followed  in  such  a  manner  as  to 
trace  with  exactness  the  various  periods  of  their  formation. 
Their  existence  and  perfection  are  not  of  so  great  importance 
during  intra-uterine  life  as  that  of  the  intestinal  tube,  kidneys, 
bladder,  etc. ;  they  do  not  exhibit,  like  these  organs,  appreciable 
stages  of  formation ;  and  from  their  first  appearance,  which 


376  ON   THE    DISEASES   OP    INFANTS. 

occurs  about  the  second  or  third  month  of  conception,  there  is 
already  distinguished  a  canal,  enlarged  at  its  superior  part,  and 
divided  inferiorly  in  a  manner  which  enables  us  to  recognise 
evidently  the  traces  of  the  larynx  and  trachea  ;  and  at  the  third 
month  transverse  lines  may  be  seen  indicating  the  cartilaginous 
rings  of  the  trachea.  At  six  and  seven  months  it  is  easy  to  dis 
tinguish  the  projections  and  depressions  which  form  the  ventri- 
cles and  cords  of  the  glottis.  The  mucous  membrane  which 
covers  these  parts  is  usually  of  a  deep  rose-color;  this  color  is 
less  vivid  in  the  trachea  where  the  internal  membrane  often  ap 
pears  in  longitudinal  folds,  which  disposition  of  the  part  permits 
an  enlaro^ement  of  the  canal  whenever  it  is  distended  with  air. 
It  is  likewise  common  to  find  very  clear  and  ropy  mucosities  co- 
vering and  lubricating  the  walls  of  the  trachea.  At  the  period 
of  birth,  the  cartilages,  bones,  and  muscles  of  the  larynx  are  per- 
fectly developed,  although  small  and  very  flexible  ;  and  the  car- 
tilages of  the  trachea  perfectly  distinct  from  each  other,  are  soft, 
and  filled  with  blood  ;  and  there  are  often  found  transverse  red 
striee,  corresponding,  in  infants  at  birth,  to  the  cartilages  of  the 
trachea,  and  which  ought  not  to  be  taken  for  marks  of  inflam- 
mation. 

The  congenital  malformations  of  the  larynx  and  trachea  are 
of  much  less  common  occurrence  than  those  of  many  other  or- 
gans ;  the  complete  absence  of  these  parts  occurs  in  cases  of  ace- 
phalia.  The  larynx  may  be  of  extreme  smallness  or  only  very 
narrow,  of  which  I  have  given  an  instance  in  the  article  on  mal- 
formations of  the  tongue ;  the  absence  or  imperforation  of  the 
epiglottis,  and  of  some  one  of  the  cartilages  of  the  larynx,  have 
been  also  observed.  I  have  seen  in  an  infant  at  birth,  a  strongly 
marked  defect  of  symmetry  between  the  two  lateral  portions  of  the 
larynx.  All  these  malformations  are  of  little  importance  at  a  pe- 
riod when  the  functions  of  this  organ  with  respect  to  phonation, 
are,  as  it  were,  a  nullity;  but  they  may  afterwards  injure  speech 
or  singing.  The  divisions  of  the  trachea  may  differ  greatly  in 
size  and  extent,  and  in  this  respect  correspond  to  a  similar  diffe- 
rence in  the  size  of  the  lungs. 

Diseases  of  the  larynx  and  trachea^  developed  before  or  du- 
ring birth. — I  have  not  seen  any  evident  trace  of  inflammation 
during  intra-uterine  life,  but  I  have  often  met  with  a  very  con- 


ON   THE    DISEASES    OF    INFANTS.  377 

siderable  sanguineous  congestion  in  premature  children ;  several 
times  this  congestion,  known  by  a  deep  redness  of  the  laryngo- 
tracheal mucous  membrane,  was  accompanied  by  a  sanguineous 
exhalation,  which  extended  even  to  the  bronchias,  so  that  it  ap- 
peared probable  that  it  was  the  result  of  an  afflux  of  blood  to- 
wards these  parts,  either  during  the  latter  period  of  intra-uterine 
life  or  during  birth. 

There  is  a  condition  of  the  larynx  and  trachea  which,  with 
out  having  reference  to  any  lesion  whatever  of  the  mucous 
membrane,  does  not  the  less  merit  the  notice  of  physicians,  and 
especially  of  accoucheurs.  I  allude  to  the  abundant  mucosity 
which  in  some  infants  obstructs  the  larynx  and  trachea,  to  that 
degree  as  materially  to  hinder  the  establishment  of  respiration. 
This  affection  is  usually  accompanied  with  a  peculiar  altera- 
tion of  the  cry,  which  is  husky  and  almost  always  incom- 
plete. The  reprise  is  not  heard  but  momentarily,  and  when 
heard  is  hoarse  and  jerking.  It  is  probable  that  this  mucosity 
was  accumulated  in  the  larynx  and  trachea  before  birth.  The 
trifling  effects  of  this  accumulation  are  but  of  short  duration  ;  a 
few  efforts  of  inspiration  and  expiration  are  sufficient  to  render 
the  cry  free  and  perfect.  The  accoucheur  may  assist  the  dis- 
charge of  this  mucosity  with  the  fingers  or  a  feather  introduced 
into  the  entrance  of  the  larynx,  where  it  usually  adheres.  I  have 
sometimes  seen  on  the  internal  surface  of  the  trachea  of  a  dead 
foBtus,  small  violet-colored  patechiae,  but  know  not  to  what  cause 
to  attribute  them. 

Diseases  developed  after  birth. — There  are  three  kinds  of  dis- 
eases affecting  the  larynx  of  sucking  children — congestions,  in- 
flammation, and  oedema. 

Congestions. — The  larynx  is  almost  always  injected  in  in- 
fants at  birth  ;  this  injection,  after  continuing  for  some  time,  will 
gradually  cease,  and  finally  disappear  altogether.  In  infants  of 
two  to  four  months,  the  mucous  membrane  of  the  larynx  is  of  a 
pale  rose,  and  its  color  differs  less  from  that  of  the  trachea  than 
it  originally  did.  During  life  the  larynx  is  easily  injected,  and 
it  is  always  found  more  less  red  in  almost  every  case  of  death 
from  asphyxia.  I  have  frequently  noticed  ecchymosis  in  the 
cellular  tissue  surrounding  the  lar^aix,  as  if  external  violence 
had  been  used  to  effect  strangulation.  In  these  cases  of  laryngeal 

48 


378  ON   THE    DISEASES    OF    INFANTS. 

congestions,  blood  has  likewise  sometimes  been  found  exhaled  to 
a  greater  or  less  extent  on  the  surface  of  the  larynx  and  trachea  ; 
this  blood  has  also  been  expectorated  by  the  infant  at  the  period 
of  death  in  considerably  quantities.  This  is  particularly  observ- 
ed in  those  infants  in  whom  the  cellular  tissue  is  oedematous  or 
hard,  and  who,  at  the  same  time,  exhibit  an  evident  universal 
plethora. 

Inflammation. — Laryngitis  is  of  common  occurrence  among 
infants  at  the  breast,  but  it  is  to  be  remarked  that  it  is  much  less 
frequently  seen  than  at  a  more  advanced  age.  It  may  be  simply 
an  erythematic  inflammation,  or  it  may  be  complicated  with  the 
formation  of  pellicular  concretions. 

The  erythematic  variety  may  vary  much  with  respect  to  its 
intensity  ;  it  may  be  of  a  rose-color  without  any  alteration  of  tex- 
ture ;  it  is  sometimes  accompanied  with  tumefaction,  or  with 
softening  or  ulceration  of  the  mucous  tissue. 

The  causes  of  laryngitis  are  sometimes  difficult  to  ascertain ; 
it  may,  however,  arise  from  the  impression  of  cold  moist  air,  the 
action  of  cold  wind,  or  wet  feet,  but  above  all,  from  prolonged 
cries  ;  it  may  also  be  produced  by  a  previous  phlegmasia  occu- 
pying some  other  point  of  the  mucous  membrane  of  the  respira- 
tory passages. 

This  inflammation,  even  in  its  mildest  form,  is  accompanied 
with  an  abundant  secretion  of  mucosity,  which  is  at  first  clear, but 
soon  becomes  thick  and  yellow.  The  respiration  of  the  child  is 
labored,  and  the  cry  sensibly  altered.  This  alteration  consists 
more  in  its  tone  than  in  its  form  ;  both  parts  constituting  the  cry 
exist,  but  they  are  husky.  When  inflammation  of  the  larynx  is 
violent,  the  alteration  in  the  cry  is  more  evident ;  it  is  often  then 
so  faint  as  scarcely  to  be  heard,  whilst  the  reprise  is,  on  the  con- 
trary, acute  and  predominant.  This  particular  modification  of 
the  cry  of  a  child,  as  I  have  already  remarked  at  the  commence- 
ment of  this  work,  is  a  positive  sign  that  inflammation  exists 
about  the  upper  portion  of  the  air  passages,  while  the  complete 
absence  of  the  reprise  indicates  a  lesion  in  the  bronchial  ramifi- 
cations or  the  pulmonary  tissue.  It  is  important  to  remember 
this  rule. 

Laryngitis  rarely  exists  alone ;  it  yery  often  follows  coryza, 
and  is  sometimes  soon  accompanied  by  inflammation  of  the  tra- 


ON    THE    DISEASES    OF    INFANTS.  379 

chea  and  bronchise  ;  it  is  also  not  uncommo.n  to  see  inflamma- 
tion of  the  larynx  occur  only  after  that  of  the  nasal  fossae. 
The  progress  of  the  symptoms  of  this  affection  is  usually  rapid, 
and  sometimes  very  obscure  at  its  first  appearance ;  but  so  soon 
as  the  inflammation  becomes  less  intense,  the  alteration  in  the 
tone  and  form  of  the  cry  will  enable  the  practitioner  to  recognise 
the  disease  without  any  difficulty ;  besides,  it  may  be  in  our  power, 
at  times,  to  satisfy  ourselves  by  inspecting  the  velum  and  sur- 
rounding parts,  for  the  inflammation  will  extend  even  to  them  ; 
and  an  erythematic  redness  extending  to  the  larynx  may  be  seen 
upon  opening  the  mouth  and  pressing  down  the  tongue. 

This  inflammation  is  seldom  accompanied  with  vomiting,  like 
that  of  the  pharynx  or  oesophagus ;  yet  the  child  sucks  badly, 
and  if  too  large  a  quantity  of  milk  be  taken  into  the  stomach,  it 
will. often  happen,  at  the  moment  of  deglutition,  that  the  pain 
caused  by  the  movement  of  the  pharynx  will  cause  him  to  leave 
the  nipple  and  give  a  sudden  cry,  causing  the  fluid  introduced 
into  the  cesophagus  to  reflow  towards  the  mouth  ;  and  some  of 
it  also  penetrating  the  larynx,  produces  a  sudden  suflx)catin^ 
cough  to  the  great  danger  of  the  child.  This  regurgitating 
movement,  with  the  cough  and  suffocation  following  it,  deserves 
our  attention.  In  three  children,  who,  when  sucking,  almost  al- 
ways experienced  this  suffocating  cough  on  swallowing,  I  found 
a  pulmonary  congestion  and  an  intense  anginose  affection, 
which  were  probably  its  cause. 

A  quantity  of  muCosity  accumulated  in  the  larynx  may  pro- 
duce similar  symptoms  ;  this  occurs  when  the  child  is  sleeping, 
who  awakes  with  a  sudden  start,  and  coughs,  making  an  effort 
at  crying,  which  however  is  only  accomplished  when,  with  the 
most  painful  exertion,  the  mucosity  obstructing  the  passage  to 
the  glottis  is  removed.  I  will  here  make  a  general  remark  in 
relation  to  inflammations  of  the  larynx  in  young  infants  ;  when 
the  passage  is  very  narrow,  the  least  tumefaction  resulting  from 
inflammation  may  produce  suffocation,  followed  by  spasm  and 
distress,  during  the  existence  of  which  the  physiognomy  fully 
expresses  the  suflfering  of  the  patient.  The  face  becomes  purple, 
especially  around  the  alas  of  the  nose  and  about  the  mouth  ;  the 
nostrils  dilate,  the  mouth  remains  wide  open,  and  at  each  move- 
meat  of  inspiration,  there  occurs  a  kind  of  spasmodic  contraction 


380  ON    THE    DISEASES    OF    INFANTS. 

of  all  parts  of  the  body,  accompanied  with  a  dilatation  of  the 
walls  of  the  thorax :  this  spasmodic  state  is  observed  in  the 
youngest  infants.  It  is  without  doubt  this  assemblage  of  symp- 
toms, to  which  authors  have  given  the  name  of  angina  sufFoca- 
toria.  It  is  frequently  noticed  in  infants,  and  I  have  almost 
always  observed  in  those  that  have  died  of  this  disease,  a  large 
quantity  of  thick  mucosity,  which  being  collected  in  the  cavity 
of  the  larynx,  and  having  caused  an  obstruction,  produced  as- 
phyxia. The  following  case  presents  something  analogous  to 
what  I  have  stated. 

CASE  LX. — Augusta  Borlet,  aged  thirteen  days,  entered  the 
infirmary  on  the  22d  of  May.  This  child  was  strong  but  pale. 
There  had  for  two  days  existed  considerable  vomiting ;  the  tongue 
was  red  at  the  point:  the  pulse  exhibited  nothing  worthy  of  remark. 
(Sweetened  rice-water,  emollient  injection,  milk  and  water.)  From 
the  twenty-second  to  the  twenty-sixth,  no  remarkable  symptom  ex- 
isted ;  but  at  this  period,  there  occurred  a  coryza,  accompanied  with 
an  abundant  secretion  of  nasal  mucosity,  and  a  slight  swelling  of  the 
nose ;  the  eyelids  were  also  a  little  tumefied.  The  coryza  soon  dis- 
appeared, and  the  child  appeared  tolerably  well  until  the  10th  of  June. 
The  respiration  then  became  painful,  the  face  purple  for  a  moment, 
and  when  the  child  awoke,  the  cry  was  for  a  short  time  husky,  and 
did  not  become  clear  until  after  several  efforts  at  respiration ;  and 
although  both  parts  could  be  heard,  yet  there  always  existed  some- 
thing obscure  or  husky,  which  was  not  natural.  (Pectoral  ptisan, 
sinapised  cataplasm  to  the  feet,  linctus,  diet.)  On  the  fifteenth,  the 
child  grew  pale  and  thin,  and  suffered  occasionally  a  severe  suffoca- 
tion, but  the  efforts  at  coughing  and  vomiting  caused  the  ejection  of 
a  quantity  of  thick  mucosity ;  the  hands  were  often  purple  ;  there 
neither  existed  diarrhoea  nor  vomiting — pulse  from  fifty-eight  to 
sixty.  On  the  eighteenth,  the  cry  was  still  husky,  the  respiratory 
movements  were  quick  and  short,  the  thorax  gave  a  dull  sound  at 
its  posterior  part,  and  an  imminent  suffocation  occurred  whenever 
drink  was  given.  On  the  twentieth,  he  was  so  feeble  and  sunken, 
that  no  symptom  could  be  observed ;  he  gradually  wasted  away  and 
died  on  the  twenty-third. 

Post  mortem  examination. — Injection  of  the  base  of  the  tongue, 
an  intense  redness,  tumefaction,  and  softening  of  the  mucous  mem- 
brane of  the  larynx,  the  walls  of  which  were  covered  with  thick  and 
almost  membranous  mucosity.    The  trachea  and  bronchiae  were  of  a 


ON    THE    DISEASES    OF    INFANTS.  381 

violet  red  ;  the  lungs  very  much  engorged  at  their  posterior  border. 
In  the  ileon,  there  were  fourteen  inflamed  follicular  patches ;  the 
colon  was  covered  with  a  number  of  brown  striae,  the  brain  was 
perfectly  healthy. 

We  have  seen  in  this  child  the  ordinary  accompaniments  of 
inflammation  of  the  larynx  continued  for  a  length  of  time,  and 
it  cannot  be  questioned  that  the  imminent  suffocation  which  oc- 
curred from  time  to  time  was  owing  to  the  presence  of  thick  mu- 
cosity  accumulated  in  the  larynx,  and  to  its  narrowness  from  the 
tumefaction  of  its  walls.  We  should  also  remember  that  it  fol- 
lowed the  coryza,  which,  as  has  been  already  observed,  is  of  very 
frequent  occurrence  in  young  infants. 

Laryngitis  does  not  always  exist  alone ;  it  often  arises  in  the 
course  of  some  other  disease,  as  scarlatina  or  variola.  The  ana- 
tomical characters  of  the  inflammation  are  not  then  confined  to 
the  erythematic  redness,  but  they  are  sometimes  analogous  to  the 
cutaneous  phlegmasia?  of  which  this  disease  is  a  concomitant 
symptom.  Pustules,  similar  to  those  of  the  variolous  eruption, 
are  frequently  seen  developed  in  the  trachea  and  pharynx ;  in 
this  case  the  symptoms  are  the  same  as  those  just  described,  at 
least  when  the  phlegmasia  is  not  complicated  with  the  formation 
of  a  pellicular  concretion,  and  then  the  symptoms  are  those 
which  characterize  croup. 

This  affection  may  terminate  in  resolution  at  the  end  of  a  few 
days,  pass  into  a  chronic  state,  as  we  have  seen,  in  the  subject 
of  the  preceding  case,  or  soon  end  fatally  from  asphyxia.  The 
disease  should,  therefore,  be  watched  with  great  care  from  the 
commencement,  that  it  may  be  effectually  combated  before  it 
has  made  much  progress. 

After  the  disappearance  of  the  inflammatory  symptoms,  the 
cry  continues  sometimes  husky,  arising  from  the  altered  state  of 
the  tissue  from  the  inflammatory  action,  affecting  the  integrity 
of  the  sound  produced  by  the  air  in  the  larynx.  I  have  often 
observed  in  adults  who  have  had  the  small  pox  in  their  earliest 
infancy,  a  peculiar  huskiness  of  voice,  produced  without  doubt 
by  the  extension  of  the  phlegmasia  to  the  larynx,  the  texture 
of  which  had  been  either  modified  or  altered. 

Treatment. — When  symptoms  of  an  anginose  affection  are 


382  ON    THE    DISEASES    OF    INFANTS. 

perceived  in  an  infant  at  the  breast,  we  ought  in  the  first  place 
to  endeavor  to  prevent  its  taking  too  much  milk  at  one  time,  and 
particularly  its  sucking  with  eagerness ;  hence  it  should  be  put 
to  the  breast  frequently  and  for  a  short  time.  If  the  inflamma- 
tion be  intense  and  deglutition  painful,  it  will  be  necessary  to 
suspend  sucking  altogether,  to  keep  the  neck  warm  by  means  of 
a  double  woollen  cravat,  or  a  poultice,  to  apply  two,  three,  or  four 
leeches,  according  to  the  age  and  strength  of  the  child,  above 
the  clavicle,  some  distance  from  the  seat  of  the  disease.  The 
clothes  should  not  be  too  tight ;  for  the  difiiculty  of  respiration 
is  already  very  great  from  the  tumefaction  of  the  larynx,  without 
our  adding  more  by  the  distress  which  may  result  from  com- 
pressing the  thorax.  .  Hot  cataplasms  to  the  feet  are  sufficient 
oftentimes  to  produce  in  them  a  slight  rubefaction ;  the  applica- 
tion of  mustard  in  young  infants  wiir  often  cause  great  irritation 
and  inflammation,  terminating  in  ulcers  very  difficult  to  cure. 
If  the  intestinal  tube  be  healthy,  and  if  there  exist  any  constipa- 
tion of  the  bowels,  two  or  three  grains  of  calomel  followed  by 
a  half  an  ounce  of  manna  dissolved  in  two  ounces  of  milk,  or  by 
an  injection  of  half  an  ounce  of  castor  oil,  incorporated  with 
warm  water  by  means  of  half  of  a  yelk  of  an  egg.  Should  any" 
cerebral  complication  arise,  it  will  be  necessary  to  apply  one  or 
two  leeches  behind  each  ear  ;  revulsives  may  also  be  employed 
at  the  same  time. 

Should  the  disease  become-  chronic,  after  having  used  the 
means  just  enumerated,  recourse  must  be  had  to  a  blister  applied 
to  the  neck,  or  ammoniated  liniment,  or  tartar  emetic  ointment  may 
be  applied  by  friction  to  the  lateral  parts  of  the  neck.  After  the 
disappearance  of  the  disease,  it  would  be  well  to  keep  the  neck 
of  the  child  for  some  time  enveloped  in  some  fine  fur,  or  swans- 
down,  or  even  a  piece  of  flannel,  to  guard  against  a  relapse,  which 
would  be  more  serious  than  the  first  attack. 

Inflammation  with  altered  secretion^  or  croup. — Croup  con- 
sists of  an  inflammation  of  the  larynx  and  trachea,  complicated 
with  the  rapid  formation  of  a  pellicular  concretion  spread  over 
the  walls  of  the  larynx,  and  is  propagated,  in  some  cases,  even 
to  the  trachea  and  bronchise. 

The  remote  causes  appear  to  be  the  same  as  those  of  laryngitis 
or  bronchial  catarrh  ;  but  it  is  difficult  to  explain  in  a  satisfac- 


ON    THE    DISEASES    OF,   INFANTS.  383 

tory  manner  the  immediate  cause  of  the  formation  of  the  false 
membrane  which  occurs  in  this  affection.  It  is  almost  always 
during  the  prevalence  of  epidemic  catarrh,  or  hooping  cough, 
that  the  croup  is  most  rife ;  it  precedes  or  accompanies  one  or 
the  other  of  these  phlegmasiss,  and  is  sometimes  even  a  compli- 
cation of  them.  M.  Bretonneau  has  in  vain  attempted  to  sepa- 
rate the  connection  existing  between  the  catarrhal  affections  and 
croup;  and  to  controvert  the  opinions  that  have  been  held  for 
half  a  century  by  Home,  Rosen,  Michaelis,  and  supported  by 
Jurine,  M.  Double,  Vieusseux,  Royer-Collard,  MM.  Blaud, 
Valentin,  Bricheteau,  and  Desruelles.*  The  physicians  who, 
with  M.  Bretonneau,  have  maintained  opinions  opposite  to  those 
of  the  authors  just  mentioned,  have  endeavored  to  prove  that 
there  is  something  specific  in  the  nature  of  croup  ;  but  without 
admitting  that  there  is  any  thing  specific  in  it,  the  formation 
of  the  false  membrane  which  characterizes  it,  may  be  explained 
to  a  certain  extent.  I  have  already  considered  this  subject  in 
detail,  in  an  essay  inserted  in  the  "  Archives  generales  de  mede- 
cine"  for  the  month  of  December,  1826.  The  following  is  the 
recapitulation  of  the  reasons  for  believing  it  in  our  power  to 
explain  in  what  consists  the  peculiar  nature  of  croup. 

1st.  There  exists,  as  it  were,  but  a  degree  between  the  thick, 
tenacious,  filamentous  mucosity  with  which  inflamed  mucous 
membranes  cover  themselves,  and  the  membranous  exudation 
of  croup.  2dly.  The  membrane  of  croup  presents  nearly  the 
same  chemical  elements  as  this  mucosity  where  fibrin  predomi- 
nates. We  have  already  seen  the  same  analogy  between  the 
pellicular  excretion  of  muguet  and  the  mucosity  of  catarrhal 
affections ;  so  that  the  puriform  mucosity  of  catarrh,  the  false 
membrane  of  croup,  and  the  excretion  of  muguet  appear  to  be 
but  alterations  of  the  same  secretion,  and  vary  only  with  respect 
to  their  form,  and  the  parts  they  occupy.  3dly.  Before  this 
membrane  appears,  the  mucous  membrane  is  always  much  in- 
flamed, red,  and  gorged  with  blood:  the  subjacent  tissue  also 
participates  in  this  injection,  and  when  the  inflamed  membrane 
is  at  the  same  time  the  seat  of  sanguineous  exhalation,  this  exha- 
lation is  seen  to  be  accompanied  or  followed  by  pellicular  concre- 
tions, from  which  it  is  to  be  inferred  that  croup  is  a  catarrhal 

*  Traite  theorique  et  pratique  du  croup.     Paris,  1824. 


384  ON   THE    DISEASES    OP    INFANTS. 

phlegmasia,  but  that  the  blood  destined  to  the  secretion  of  muco- 
sity  is,  in  the  case  under  consideration,  concentrated  in  greater 
abundance,  or  rendered  plastic  by  inflammation,  and  imparts  to 
the  mucosity  that  portion  of  its  composition  which  concretes  the 
quickest,  that  is,  the  fibrin ;  whence  arise  the  striae,  pellicles,  and 
white  patches  with  which  the  mucous  membranes  affected  with 
mug:uet  or  croap  are  covered. 

Children  at  the  breast  are  much  less  subject  to  croup  than 
those  of  a  more  advanced  age.  It  is  between  the  ages  of  two 
years  to  eight  or  ten  that  this  disease  is  the  most  prevalent. 
Young  infants,  however,  are  liable  to  pellicular  inflammations  of 
other  mucous  membranes,  such  as  those  of  the  mouth,  oesopha- 
gus, and  nasal  fossae,  whilst  the  opposite  condition  exists  in  chil- 
dren of  more  mature  age.  Age,  therefore,  and  the  organic  modi- 
fications which  appertain  to  it,  and  which  can  more  easily  be 
understood  from  their  effects  than  by  their  physical  appearances, 
seem  to  produce  a  difference  which  ought  to  be  noted,  although 
we  are  unable  to  explain  it.  But  on  the  other  hand,  the  readiness 
with  which  symptoms  of  suffocation  arise  when  the  slightest 
inflammation  is  manifested  in  the  air  passages  of  young  infants, 
render  the  ordinary  tracheal  and  laryngeal  affections  almost  as 
dangerous  as  croup :  we  should  on  this  account  watch  with  the 
greatest  care  the  development  and  progress  of  the  symptoms  of 
laryngo-tracheal  inflammation  in  infants. 

From  what  I  have  said  of  the  greater  frequency  of  croup  at 
an  age  more  advanced  than  that  of  the  children  whose  diseases 
form  the  object  of  this  work,  I  will  not  enter  into  a  detailed  his- 
tory of  this  disease,  on  which  a  number  of  monographs  have 
been  published  ;*  but  will,  therefore,  only  give  succinctly  the 
progress  of  the  symptoms  and  the  treatment  of  the  disease. 

Symptoms. — When  the  pellicular  formation  occurs  on  the  in- 
flamed surface  of  the  larynx,  the  cry  is  altered  ;  the  reprise  only 
is  heard ;  it  is  acute  and  sudden,  like  the  crowing  of  a  young 

♦  Consult,  Home,  Inquiry  into  the  nature  and  cure  of  croup.  Edinburgh,  1T78. 
Michaelis,  De  angina  poliposd  seu  memhranacea.  Arigentorati,  1778.  Royer-Col- 
lard,  Rapp.  sur  les  Memoires  Vieusseux,  Jurine,  Albers  de  Bremen,  Caillau,  Double. 
Desruelles,  Traite  du  croup.  Bland,  Nouvelles  reserches  .lur  laryngo-trachiitc. 
Bretonneau,  De  la  Diphtherite.  Bricheteau,  Precis  analytique  du  croup.  Also  the 
excellent  work  of  M.  Valentin. 


ON   THE    DISEASES    OF    INFANTS.  385 

cock  ;  sometimes  also  it  is  even  very  much  smothered.  The  cry 
proper  is  no  longer  heard  except  momentarily,  or  if  renewed,  is 
much  altered.  The  cough  which  occurs  in  paroxysms,  produ- 
ces in  the  child  the  greatest  anxiety ;  the  most  painful  efforts  at 
inspiration  are  made,  and  it  is  then  that  the  interval  of  the  cry 
exhibits  the  characters  of  which  I  have  spoken.  The  painful- 
ness  of  respiration  is  almost  constant,  but  it  is,  besides,  subject  to 
very  evident  exacerbations  and  intermissions.  To  these  symp- 
toms, the  commencement  and  return  of  which  are  almost  always 
sudden,  is  to  be  added  pain  in  the  larynx,  of  which  infants  at  the 
breast  are  unable  to  indicate  the  existence  in  any  other  way  than 
by  continually  carrying  the  hand  towards  that  part,  as  if  to  re- 
move something — a  distress  which  is  always  augmented  when- 
ever there  is  an  exacerbation  of  the  cough;  nasal  hemorrhages, 
which  are  very  rare  in  young  infants,  and  consist  rather  of  a 
sanguineous  expansion  than  of  true  hemorrhage ;  and  lastly, 
drowsiness,  which  is  a  frequent  and  severe  concomitant  symp- 
tom of  croup,  indicating  a  cerebral  congestion,  or  even  the  exist- 
ence of  acute  hydrocephalus,  a  lesion  of  very  common  occur- 
rence in  infants  that  have  died  of  croup.  A  greater  or  less  quan 
tity  of  the  pellicle  is  rejected  by  vomiting  and  expectoration, 
when  great  relief  is  experienced,  until  a  renewal  of  it  again  ob- 
structs the  air  passages,  causing  a  return  of  strangulation,  to 
which  the  child  is  every  instant  exposed.  Death  almost  always 
suddenly  terminates  this  frightful  disease,  against  which  the  re- 
sources of  art  are  too  often  powerless. 

Treatment. — Two  distinct  conditions  present  themselves  in 
croup  ;  inflammation,  which  is  the  primary  cause  of  all  the  other 
symptoms,  and  the  suifocation,  either  mechanical  or  spasmodic, 
produced  by  the  membrane  which  forms  in  the  trachea  and  la- 
rynx. 

All  the  means  which  have  been  pointed  out  for  the  treatment 
of  ordinary  laryngo-tracheal  inflammation — such  as  sanguineous 
evacuations,  general,  and  local  cupping, emollient  drinks,  topical 
emollients  to  the  throat,  revulsives  to  the  skin  and  intestinal 
tube — should  be  actively  employed  from  the  commencement  of 
this  disease. 

Symptoms  of  suflTocation  arise  not  only  from  the  mechanical 

embarrassment  caused  by  the  membranous  formation,  but  hke- 

49 


386  ON   THE    DISEASES   OP   INFANTS. 

wise  from  a  kind  of  spasm  of  the  larynx,  as  has  been  remarked  by 
all  authors.  Therefore,  while  we  attempt  the  removal  of  the 
membrane  by  emetics,  it  will,  at  the  same  time,  be  necessary  to 
administer  some  antispasmodic,  as  an  injection  containing  eight 
or  ten  grains  of  assafoetida,  or  a  few  drops  of  tincture  of  castor,  or 
frictions  on  the  throat,  with  a  liniment  composed  of  camphorated 
oil  of  chamomile,  or  what  is  still  better,  with  a  mixture  of  ether 
and  water.  There  is  still  another  remedy  which  must  not  be 
neglected,  and  the  us€  of  which  M.  Guersent  strongly  recom 
mends.*  It  is  a  bath  at  the  temperature  of  twenty-five  degrees, 
(88^^  Pahr.)  or  more.  Nothing  calms  the  restlessness  of  the 
child  more  than  this,  who  should  be  kept  in  it  as  long  as  possi- 
ble, taking  the  precaution  to  cover  the  bath  so  that  the  vapor 
which  arises  may  not  determine  an  afflux  of  blood  to  the  head, 
which  would  be  very  injurious.  It  is  almost  always  necessary 
also  to  apply  two  or  three  leeches  about  the  mastoidean  region,  to 
meet  the  symptoms  of  meningitis  or  hydrocep>halus,  which  are 
sometimes  observed  in  infants  affected  with  croup.  In  addition 
to  these  means  it  will  be  well  to  apply  a  blister  to  the  legs  or 
thighs,  or  to  rub  the  lower  parts  of  the  throat  with  ammoniacal 
liniment,  or  tartar  emetic  ointment.  I  saved  a  child  of  the  age 
of  fifteen  months,  affected  with  croup,  by  using  for  three  days 
the  various  means  which  I  have  advised :  after  employing  local 
bleeding  and  baths,  and  purged  with  calomel,  I  had  recourse  to 
syrup  of  ipecacuanha,  which  was  quickly  followed  by  an  abun- 
dant expectoration  and  vomiting,  discharging  thereby  a  quantity 
of  the  membranous  formations.  This  treatment  was  pursued  for 
three  days  without  intermission,  when  the  symptoms  of  croup 
disappeared ;  the  cry,  however,  continued  hoarse. 

Subsequent  observations  have  satisfied  me  of  the  advantages 
arising  from  the  use  of  calomel  administered  in  repeated  doses 
from  the  commencement  of  the  disease.  It  appears  to  act  by 
augmenting  and  modifying  the  secretion  of  the  mucous  mem- 
branes, which  are  in  this  manner  relieved  of  the  membranous 
formation  on  their  surface.  There  is  still  another  circumstance 
upon  which  a  great  part  of  the  utility  of  calomel  rests  in  young 
infants  who  do  not  expectorate,  but  swallow  all  that  accumulates 

♦  Article  Croup  in  the  Diet,  de  in6d.,  in  21  vols. 


ON   THE    DISEASES    OP    INFANTS.  387 

in  the  back  part  of  the  mouth — calomel  acting  not  only  in  de- 
taching the  membrane,  but  also  causes  its  expulsion  b^'  stool. 

It  often  happens  that  membranous  formation  is  not  passed  in 
a  tubular  form  with  the  foBces  ;  the  fragments  only  appear,  re- 
sulting from  the  division  of  these  false  membranes  by  the  action 
of  the  mercurial  salt,  or  from  a  kind  of  trituration  which  it  ex- 
periences in  passing  through  the  organs  of  digestion. 

I  have  never  employed  calomel  except  in  doses  of  eighteen  or 
twenty  grains  in  twenty-four  hours,  and  have  found  it  sufficient 
to  produce  the  results  intended.  At  the  same  time,  I  am  parti- 
cular in  directing  purgative  injections  during  the  mercurial 
treatment,  for  if  constipation  should  exist  there  is  a  great  risk  of 
salivation.  Mercury  usually  produces  abundant  liquid  and 
green  stools  ;  it  produces  but  little  pain,  and  no  augmentation  of 
the  general  symptoms  which  accompany  croup.  M.  Guersent 
often  incorporates  it  with  honey ;  but  I  have  remarked  that  the 
consistence  of  honey  renders  the  deglutition  tedious,  especially  in 
a  young  infant  where  the  larynx  and  pharynx  are  obstructed  by 
an  abundant  mucus.  The  retention  of  this  thick  substance  in 
the  vicinity  of  the  air  passages  contributes  also  to  render  the  re- 
spiration more  suffocating.  The  following  is  the  mixture  in 
which  I  administer  it. 

"^  Gum.  Tragacanth.  gr.  x. 
Aquae  destil.  §ij. 
Hydr.  proto-chior.  gr.  x. 
Syrup  simp. 

"      Ipecac,  a  a  fss. 
Aquse  Auran.  3j, 

This  mixture  is  to  be  shaken  every  time  it  is  to  be  given,  and 
a  teaspoonful  of  it  administered  every  half  hour. 

Yet  I  never  have  recourse  to  this  therapeutic  agent  except  in 
connection  with  direct  antiphlogistic  means,  such  as  the  applica- 
tion of  leeches  to  the  nei  hborhood  of  the  larynx  and  trachea, 
and  the  use  of  emollient  drinks  and  topical  applications. 

To  recapitulate  ;  I  have  come  to  the  conclusion— 1st,  That  it 
is  not  hazardous  to  employ  the  proto-chloride  of  mercury  in 
doses  of  eighteen  or  twenty  grains  in  twenty-four  hours  in  chil- 
dren affected  with  croup ;  2dly,  That  this  medicine  powerfully 
seconds  the  effects  of  sanguineous  evacuations ;  and  while  the  lat- 


388  ON   THE    DISEASES    OP    INFANTS. 

ter  relieves  the  inflammation,  the  mercury  expels  the  product  of 
it  from  the  system  ;  3dly,  That  supposing  it  dangerous  to  admin- 
ister this  medicine,  it  is  better  to  risit  this  danger,  than  to  aban- 
don the  child  to  the  greater  danger  of  the  disease  with  which  it 
is  affected.  In  all  cases  there  is  much  less  risk  incurred  in  using 
the  proto-chloride  of  mercury  obtained  by  sublimation  with 
aqueous  vapor.* 

Is  it  necessary,  as  M.  Bretonneau  advises,  to  open  the  trachea 
and  introduce  a  quantity  of  calomel  or  alum,  to  destroy  and  re- 
move the  membranous  pellicle  ?  My  experience  has  not  as  yet 
sufficiently  confirmed  me  in  this  measure,  and  I  should  not  feel 
authorized  in  using  it  until  after  having  made  use  of  other  and 
well-tried  means,  where  only  extraordinary  measures  are  al- 
lowable, and,  as  Hippocrates  says,  where  circumstances  become 
desperate.  I  shall  never  forget  the  case  of  a  young  girl  to  whom 
I  was  called  on  the  third  day  of  croup.  At  first  I  had  recourse 
to  the  most  energetic  antiphlogistic  measures  ;  my  efforts  being 
without  avail,  and  the  child  rapidly  approaching  her  dissolution, 
her  father,  who  was  not  ignorant  of  medicine,  forced  mej  as  it 
were,  in  his  despair,  to  use  the  new  means  which  had  been  re- 
cently advised  in  the  treatment  of  croup.  I  curved  a  piece  of 
whalebone  and  armed  it  with  a  pledget  soaked  with  a  concen- 
trated solution  of  alum,  and  introduced  it  into  the  larynx  and 
trachea ;  but  immediately  the  child,  who  was  tolerably  calm  at 
the  time,  was  seized  with  violent  convulsions,  and  perished  in 
my  arms  in  less  than  five  minutes.  Although  it  was  evident 
that  this  child  would  die,  this  distressing  accident  made  so  great 
an  impression  on  my  mind,  that  I  resolved  never  again  to  intro- 
duce any  medicinal  substance  into  the  irritated  and  inflamed  tra- 
chea of  an  infant. 

Frictions,  with  mercurial  ointment  on  the  sides  of  the  neck,  or 
calomel  given  until  an  abundant  salivation  is  produced,  have 
likewise  been  employed  with  success.  These  means  have  ef- 
fected the  removal  of  the  false  membrane,  or  entirely  prevented 
its  reproduction. 

As  croup  usually  prevails  epidemically,  it  will  be  necessary  to 


♦  See  my  Memoire  sur  Vemploi  du  calomelas  dans  le  trautment  du  croup  et  dcs  an- 
ginea  ptlliculeuses,  (Arch.  gen.  demed.  t.  xx.,    1829.)     See  Appendix,  page  594. 


ON   THE    DISEASES    OP    INFANTS.  389 

remove  those  children  that  are  not  affected  with  it,  to  places 
where  it  has  not  extended  its  ravages. 

(Edematous  affection  of  the  throat. — There  is  often  found,  on 
examining  the  bodies  of  children  who  have  died  with  symptoms 
of  an  anginose  affection,  in  place  of  a  well-marked  inflammation, 
a  greater  or  less  (Edematous  tumefaction  of  the  laryngeal  pa- 
rietes.  The  external  signs  of  this  affection  are  not  easily  recog- 
nised ;  there  is,  as  in  inflammation  of  these  parts,  an  alteration 
in  the  cry,  but  the  other  symptoms  are  less  evident,  as  this  oede- 
ma occurs  in  general  among  very  feeble  children,  and  who  con- 
sequently do  not  exhibit  a  sufficient  development  of  their  func- 
tions to  allow  of  their  disorders  to  be  appreciable.  I  have,  how- 
ever, observed  that  children  affected  with  oedema  of  the  glottis, 
had,  at  the  same  time,  an  oedema  of  the  cellular  tissue  in  various 
parts  of  the  body,  and  that  the  cry,  very  irregular,  was  almost  al- 
ways husky  and  incomplete,  and  was  also  trembling,  like  the 
bleating  of  a  goat.  It  is  to  this  modification  that  1  have  given 
the  name  of  "  Chevrotant."  I  have  seen  this  peculiar  phenome- 
non produced  in  three  infants  affected  with  oedema  of  the  glottis. 
I  will  give  an  instance  of  one  of  these. 

CASE  LXI. — Francois  Delaii,  aged  two  days,  a  very  robust  child, 
but  with  the  integuments  livid,  and  the  legs  and  feet  oedematous,  en- 
tered the  infirmary  on  the  13th  of  October;  his  cry  was  painful,  smo 
thered,  and  trembling ;  it  resembled  that  produced  by  the  action  of 
scraping  the  bow  over  the  string  of  a  violin.  His  limbs  were  cold ; 
pulse  slow,  small,  and  difficult  to  be  felt.  On  the  fourteenth,  a  general 
icterus  appeared  over  the  body.  {Sweetened  water,  milk  and  water.) 
The  extreme  difficulty  of  respiration  and  the  state  of  general  conges- 
tion of  this  child  induced  M.  Baron  to  apply  a  leech  to  each  axilla. 
The  congestion  of  the  integuments  diminished,  but  the  face  continued 
of  a  deep  red  ;  the  character  of  the  cry  continued  the  same.  On  the 
sixteenth,  a  vio.et-colored  ecchymosis  appeared  suddenly  on  the  right 
cheek,  and  extended  even  to  the  upper  lip,  which  became  the  seat 
of  a  considerable  cedematous  swelling.  The  cry  of  this  child  con- 
tinued husky  ;  the  pulsations  weie  slow,  and  so  obscure  that  it  was 
impossible  to  count  them.  Some  thick,  frothy,  sanguineous  muco- 
sity  was  passed  by  the  mouth  and  nose.     He  died  at  night. 

Post  mortem  examination. — The  mouth  was  healthy,  but  the 
glottis  presented   a  considerable  (Edematous  swelling;   the   lateral 


390  ON   THE    DISEASES    OP    INFANTS. 

walls  of  the  larynx  were  thick,  white,  and  so  tumefied,  that  they 
almost  touched.  On  pricking  them  with  the  point  of  a  scalpel,  no 
water  issued;  the  serosity  was,  as  it  were,  a  kind  of  jelly  in  the  sub- 
mucous cellular  tissue.  There  was  a  very  marked  congestion  at  the 
posterior  border  of  each  lung.  The  other  organs  of  the  body  did  not 
present  any  thing  remarkable  ;  the  liver  was  very  much  gorged  with 
blood,  and  the  bile  abundant  and  black. 

There  was  in  this  case  a  remarkable  coincidence  between  the 
oedema  of  the  limbs,  face,  and  glottis  ;  a  relation  not  less  intimate 
existed  also  between  the  circulation,  and  the  serous  infiltration 
of  which  we  have  spoken  ;  so  that  taking  into  consideration  these 
different  phenomena  and  the  peculiar  alteration  of  the  cry  in  an 
infant  whose  external  parts  were  oedematous,  one  might  be  led  to 
suspect  the  existence  of  the  disease  we  have  described.  It  is 
only  by  grouping  together  the  different  physiological  phenomena 
presented  by  a  child,  that  it  is  possible  to  draw  in  like  cases,  if 
not  a  positive,  at  least  a  probable  conclusion,  for  it  is  impossible 
to  arrive  at  a  degree  of  certainty  from  any  isolated  symptom. 

1  have  seen  this  affection  in  children  of  more  advanced  age, 
and  who  after  having  been  reduced  to  a  state  of  marasmus,  pre- 
sented an  infiltration  in  different  parts  of  the  body  at  the  same 
time.  In  some  of  them  the  cry  was  husky,  feeble,  and  incom- 
plete, but  it  never  presented,  in  its  tone,  the  peculiar  modification 
which  was  observed  in  the  preceding  case.  It  would  seem  as  if 
the  "  chevrotant"  cry  was  either  more  rare  or  more  difficult  to 
observe  in  proportion  as  children  advance  in  age. 

The  treatment  of  this  disease  need  not  be  directed  exclusively 
to  the  part  affected ;  we  have  seen  that  the  oedematous  angina 
in  the  child  whose  case  is  repeated  above,  was  accompanied  with 
a  pulmonary  congestion  and  extreme  lentor  of  the  circulation. 
Both  these  conditions  must  be  met  by  appropriate  treatment, 
which  will  be  pointed  out  below.  The  effect  will  cease  when 
the  cause  shall  have  been  directly  met.  It  is  much  more  diffi- 
cult to  treat  and  cure  oedema  of  the  glottis,  which  arises  in  in- 
fants emaciated  and  worn  out  by  some  chronic  disease,  because 
then  the  oedema  is  not  always  caused  by  an  evident  embarrass 
ment  of  the  circulation,  or  by  the  congestion  of  the  blood  in  the 
respiratory  organs.    It  will  be  necessary  in  such  a  case  to  attempt 


ON   THE    DISEASES    OP    INFANTS.  391 

the  resolution  of  the  disease  by  the  aid  of  dry  or  aromatic  fric- 
tions, seconding  the  effect  of  these  means  by  diet  and  regimen 
suitable  to  the  condition  of  the  child. 

I  cannot  advise  the  use  of  certain  aromatic  vapors  introduced 
into  the  air  passages,  for  the  narrowness  of  the  larynx  and  tra- 
chea, and  the  great  disposition  of  young  infants  to  spasm  of  these 
organs,  naturally  contra-mdicate  the  employment  of  these  means, 
which,  as  in  adults,  produce  very  uncertain,  or  perhaps  very 
little  effect. 

I  will  not  stop  to  give  a  particular  detail  of  the  diseases  of  the 
trachea;  the  history  of  their  symptoms  is  comprised  in  those  of  the 
larynx  or  bronchiae  ;  besides,  it  is  very  difficult  in  young  infants 
to  make  an  accurate  diagnosis  between  the  diseases  of  the  trachea 
and  larynx. 

Section  III. 

CASES    op    the    thoracic    PORTION    OP  THE    RESPIRATORY 
APPARATUS. 

I  shall  consider  in  this  section  diseases  of  the  lungs,  bronchiae, 
and  pleurae. 

Development  and  congenital  malformations. — I  cannot  dis- 
pense with  the  consideration  of  the  development  of  the  pectoral 
cavity,  for  if  it  perform  an  active  part  in  the  functions  of  respira- 
tion from  its  mobility,  and  as  its  alternate  dilatation  and  contrac- 
tion very  materially^  assist  the  dilatation  of  the  lungs,  its  mal- 
formations must  have  great  influence  on  the  act  of  respiration. 
Hence  I  shall  consider  together  the  development  of  the  thorax 
and  lungs. 

The  thorax  at  first  is  but  a  very  narrow  cavity,  the  walls  are 
very  thin,  consisting  of  nothing  more  than  a  flexible  pellicle,  in 
the  centre  of  which  appear  some  semicircular  white  lines,  which 
afterwards  form  the  ribs.  In  proportion  as  the  child  advances 
in  age,  and  the  lungs  are  developed,  the  thorax  becomes  more 
spacious,  its  cavity  is  developed,  more  especially  at  the  lower 
part,  for  at  first  the  abdomen  forms  almost  the  whole  of  the  trunk 
of  the  embryo ;  and  upon  its  superior  and  lateral  walls  are  seen 
two  small,  round,  and  slightly  projecting  eminences  constituting 


392  ON   THE    DISEASES    OP    INFANTS. 

the  rudiments  of  the  arms.  The  two  sides  of  the  thorax  do  not 
approach  each  other,  to  complete  the  thoracic  cavity,  for  the 
thorax  is  always  closed  unless  there  exist  some  malformation. 
At  the  period  of  birth,  the  chest  has  acquired  considerable  di- 
mensions ;  yet  with  respect  to  the  abdomen,  it  is  much  less 
capacious  than  at  a  more  advanced  age,  and  especially  than  in 
the  adult. 

During  the  time  the  pectoral  cavity  is  acquiring  an  increase 
in  its  dimensions,  the  lungs  themselves  have  also  passed  through 
their  different  stages  of  development. 

About  the  sixteenth  week,  the  lungs  first  appear ;  they  are 
much  lower  than  the  heart,  and  it  is  said  that  in  general  they 
are  less  voluminous.  I  have  been  able  to  discern  them  in  an 
embryo  of  six  weeks,  which  I  dissected  with  M.  A.  Danyau. 
The  heart  was  of  a  globular  form  and  about  the  size  of  a  millet 
seed ;  and  the  lungs,  instead  of  being  smaller,  were  united  at 
their  lateral  parts,"  under  the  form  of  two  transparent  vesicles, 
flabby  and  much  larger  than  the  heart,  and  hollow  interiorly,  as 
was  proved  by  a  magnifying  glass.  These  two  organs,  closely 
pressed  together,  were  supported  by  a  very  thin  membrane  which 
separated  the  chest  from  the  abdomen,  and  which  was  evidently 
the  diaphragm.  When  the  lungs  first  appear,  they  have  a  smooth 
white  surface ;  but  in  proportion  as  the  child  advances  in  age, 
grooves  appear  indicating  the  separation  of  the  lobes,  and  then 
lines  which  mark  the  division  of  the  lobes  appear  on  the  external 
surface  of  the  lungs ;  next  they  are  solid ;  the  veins,  arteries, 
and  bronchial  ramifications  begin  to  grow;  and  their  size  in- 
creases at  the  same  time  that  the  pectoral  cavity  enlarges,  they 
assume  a  rose  color,  and  at  the  period  of  birth  exhibit  the  ana- 
tomical characters  which  we  shall  now  consider. 

From  the  seventh  to  the  ninth  month,  the  lungs  possess  nearly 
the  form  which  they  afterwards  have  ;  but  their  color  is  different ; 
and  it  varies  in  different  children,  for  they  are  more  or  less  pale 
or  colored,  according  to  the  exsanguineous  or  plethoric  condition 
of  the  subject.  Some  lungs  exhibit  red  lichenoid  spots  on  their 
surface,  which  would  probably  become  slate-colored,  as  is  ob 
served  on  the  surface  of  the  lungs  of  an  adult ;  others,  on  the 
other  hand,  are  white,  or  of  a  faint  rose-color ;  their  color  has  a 
close  resemblance  to  those  of  an  ox  or  a  calf.   I  have  twice  seen  in 


ON    THE    DISEASES    OP    INFANTS*  393 

adults  this  extreme  paleness  of  the  lungs.  Is  this  kind  of  leuco- 
pathy  of  the  lungs  an  effect  of  an  alteration  of  the  primitive  con- 
genial color  of  the  pulmonary  tissue  ?  I  am  much  disposed  to 
believe  that  this  is  the  case. 

During  intra-uterine  life,  the  lungs  fill  the  entire  pectoral 
cavity,  against  the  sides  of  which  they  press  to  such  a  degree  as 
to  receive  the  impress  of  the  ribs,  which  are  always  more  pro- 
jecting on  the  interior  of  the  thorax  in  a  child  than  in  an  adult. 
I  mention  here  these  depressions  on  the  lungs  in  some  infants, 
that  it  may  not  be  considered  an  effect  of  a  pathological  condi- 
tion. I  have  noticed  the  same  thing  in  the  case  of  adults,  and  it 
is  possible  that  these  furrows  were  formed  during  intra-uterine 
life,  and  continued  to  an  advanced  age.  If  this  be  so,  it  ought 
not  to  be  considered  either  in  adults  or  infants  as  the  effect  of  an 
accidental  tumefaction  of  the  orp-an  ;  and  if  the  projection  of  the 
ribs  in  adults  is  not  sufficiently  evident  to  account  for  these  de- 
pressions or  notches  at  the  posterior  border  of  the  lungs,  it  is  not 
difficult  to  account  for  this  phenomenon,  by  referring  it  to  a 
period  of  life  when  the  ribs  are  more  prominent,  and  that  it  has 
maintained  the  same  appearance  notwithstanding  the  progress  of 
age.  I  have  heard  doubts  raised  by  Professor  Laennec,  on  the 
possibility  of  these  pulmonary  depressions  by  the  ribs,  because, 
he  observes,  the  latter  are  not  sufficiently  projecting  to  cause 
these  furrows :  but  the  explanation  which  I  have  given  ought 
to  dissipate  every  doubt  on  this  subject,  and  suffice  to  account 
for  these  furrows,  which  the  author  of  mediate  auscultation  has 
regarded  as  chimerical. 

When  the  thorax  of  a  child  that  has  not  respired  is  opened, 
one  is  struck  with  the  analogy  between  the  thymus  gland  and  the 
two  lungs ;  it  would  seem  as  if  this  body  was  a  third  lung,  in 
which  no  bronchial  ramifications  appear.  I  note  this  resem- 
blance, because  after  birth  the  thymus  gland,  preserving  still  the 
same  aspect,  may  serve  as  a  point  of  comparison,  and  guide  us  in 
the  examination  which  we  propose  to  make  of  the  tissue  of  the 
lungs  when  modified  by  respiration  or  not.  The  pulmonary 
tissue  in  which  the  air  has  not  penetrated,  is  flabby  and  reddish, 
like  the  tissue  of  the  spleen ;  for  notwithstanding  the  existence 
of  the  ductus  arteriosus,  which  allows  the  blood  sent   from  the 

heart  to  pass  directly  into  the  aorta,  yet  a  certain  quantity  pene- 

50 


394  ON   THE    DISEASES    OP    INFANTS. 

trates  the  lungs,  either  hy  mechanical  reflux,  or  that  because  this 
blood  is  necessary  for  the  purpose  of  nutrition  of  the  organ,  so 
that  the  pulmonary  arteries  and  veins  are  very  frequently  filled 
with  blood  at  some  distance  from  the  pulmonary  tissue.  The 
bronchiae,  usually  of  a  pale  rose,  are  sometimes  colored  by  a 
slight  sanguineous  exudation. 

After  birth  the  tissue  of  the  lungs  that  have  been  penetrated  by 
the  air  respired  by  the  child,  becomes  lighter  and  crepitating, 
and  alvi^ays  possesses  more  blood,  all  other  things  being  equal, 
than  the  lungs  of  adults.  1  will  here  mention  a  phenomenon 
which  it  is  important  to  note.  In  almost  all  young  infants,  there 
is  found  a  very  evident  sanguineous  3ongestion  at  the  posterior 
border  of  the  lungs,  and  especially  on  the  right  side.*  But  it  is 
evident  that  this  congestion  is  a  true  mechanical  phenomenon, 
and  I  am  disposed  to  believe  that  the  congestion  occurring  on 
the  right  side  among  the  children  of  the  Hospice  des  Enfans 
Trouves,  arises  from  the  common  prejudice  of  the  nurses  in  be- 
ing careful  to  lay  the  child  in  bed  on  the  right  side.  Notwith- 
standing this  congestion  of  the  pulmonary  tissue,  the  bronchiae 
are  not  always  red,  but  are  usually  distinguished  by  their  white 
appearance,  contrasting  strongly  with  the  redness  of  the  paren- 
chyma of  the  lungs.  Having  thus  rapidly  treated  of  the  develop- 
ment and  principal  characters  of  the  lungs  in  health,  let  us  make 
a  remark  on  the  malformation  of  these  organs  and  of  the  thorax. 

Both  lungs,  or  one  of  them,  together  with  one  or  both  of  the 
bronchiae,  may  be  entirely  or  partially  deficient  in  acephalous 
children.  Otto,  as  quoted  by  Meckel,  has  observed  the  occlusion 
of  the  trachea  with  an  absence  of  the  cranium.  An  extreme 
smallness  of  one  or  both  of  the  lungs,  or  a  narrowness  of  the 
pectoral  cavity,  may  occur ;  or  the  abdominal  viscera  may  be 
found  in  the  thorax  in  consequence  of  malformation  of  the  dia- 
phragm. The  lungs,  which  present  on  one  side  two  lobes,  and 
on  the  other  three,  separated  by  deep  fissures,  may  exhibit  a 
unique  mass  without  division,  or  divisions  inverse  to  those  which 
exist  in  a  normal  state,  or,  lastly,  fissures  more  or  less  numerous. 
The  inversion  of  the  right  lung  to  the  left  side,  and  vice  versa,  is 
usually  found  with  an  inversion  of  the  heart.    Finally,  they  may 

♦  Professor  Chaussier  has  a  long  time  since  remarked  this  phenomenon. 


ON    THE    DISEASES    OP    INFANTS.  395 

not  be  contained  in  the  thoracic  cavity  when  the  walls  of  this 
cavity  are  incomplete  in  consequence  of  an  original  malforma- 
tion. Haller  says  that  this  malformation  of  the  pectoral  parietes 
is  more  rare  than  that  of  the  abdomen  ;  yet  he  adds,  "  Sunt  ta- 
men  etiam  exempla  in  qaihus  sternum  costceque  imperfectce  cor 
emisenmt,  ut  nudum  appareret^  quale  in  pullo  est,  qui  priTnos 
dies  incuhationis  experiturP*  This  illustrious  writer  quotes,  in 
support  of  hiso  pinion,  cases  reported  by  Baron,  Bianchi,  Fra- 
cassini,  etc. 

Among  these  malformations,  those  of  the  pectoral  cavity  which 
may  oppose  a  free  expansion  of  the  lungs  in  the  act  of  respira- 
tion, will  cause,  in  new-born  children,  symptoms  of  a  nature  more 
or  less  serious.  It  can  be  easily  conceived  that  when  a  congeni- 
tal diaphragmatic  hernia  exists,  and  the  stomach,  omentum,  or 
intestines  are  introduced  into  the  thoracic  cavity,  a  considerable 
obstacle  will  exist  to  the  proper  dilatation  of  the  lungs,  and  give 
rise  to  a  variety  of  symptoms.  It  is  not  necessary  that  there 
should  be  so  great  a  malformation  in  that  cavity  to  produce  an 
evident  disturbance  in  the  functions  of  the  respiratory  appara- 
tus ;  the  simplest  malformation  will  sometimes  give  rise  to 
symptoms  that  would  almost  lead  to  the  belief  that  they  were  the 
result  of  a  lesion  of  the  bronchiae,  pleura,  or  lungs.  These 
symptoms  may  perhaps  be  litde  apparent  at  the  period  of  birth, 
but  in  proportion  as  the  child  advances  in  age,  and  the  functions 
of  respiration  become  developed,  and  the  necessity  of  a  greater 
expansion  of  the  parietes  of  the  thorax  arises,  when  they  are  too 
narrow,  or  too  much  depressed,  they  oppose  the  dilatation  of  the 
lungs,  producing  symptoms  which  might  be  attributed  to  some 
lesion  of  the  lungs  or  bronchige,  if  post  mortem  examinations  did 
not  prove  their  integrity. 

CASE  LXII. — Malformation  of  the  thorax,  dyspncea.— Andre 
Alpin,  aged  ten  months,  entered  he  infirmary  on  the  14th  of  Au- 
gust. This  child  was  pale  and  thin  ;  the  chest  exhibited  at  the 
sides  a  considerable  depression  ;  the  limbs  were  long,  and  the  arti- 
culations were  very  large  ;  there  existed  the  commencement  of  a  gib- 
bosity at  the  dorsal  region  of  the  vertebral  column  ;  the  abdomen  v^as 
constantly  swelled.     This  child  had  been  affected  for  three  months 

*  Opera  minora — De  monstris^  chap.  v. 


396  ON   THE    DISEASES    OF    INFANTS. 

with  a  continual  cough  and  dyspnoea,  which  increased  whenever  he 
was  laid  down  upon  the  back,  or  moved  about.  His  sleep  was 
often  interrupted  by  a  sudden  choking,  which  ceased  almost  im- 
mediately upon  raising  him.  The  heat  of  the  skin  was  very  great 
and  burning ;  the  pulse  was  small,  thready,  and  frequent ;  per- 
cussion gave  only  a  dull  sound.  [Linctus,  gummed  marshmal- 
low  water,  milk  and  water.)  On  the  sixteenth,  the  same  general 
state  continued  ;  cry  painful  and  short.  On  the  seventeenth,  rest- 
lessness ;  violet  tint  of  the  face,  cry  plaintive,  face  painful,  pulse 
quick,  heat  burning.  (Four  leeches  to  the  base  of  the  thorax, 
sinapism  to  the  feet,  gummed  marshmallows,  diet.)  After  this, 
the  child  presented  nearly  the  same  appearance  ;  he  did  not  ap- 
pear to  have  experienced  much  relief  from  the  application  of  the 
leeches  ;  he  became  pale,  was  less  restless,  respired  with  difficulty, 
and  died  on  the  23d  of  August. 

Post  mortem  examination. — The  oesophagus  was  healthy;  the 
mucous  membrane  of  the  stomach  was  of  a  brown  color,  and  con- 
tracted in  wrinkles  ;  an  abundant  mucosity  existed  in  the  small  in- 
testines, the  internal  membrane  of  which  was  thick,  soft,  and  color- 
less ;  a  tumefied  follicular  plexus  of  a  slightly  red  coJor  existed  in  the 
inferior  third  of  the  ileon,  and  a  follicular  eruption  in  the  colon.  The 
lungs  and  bronchia?  were  perfectly  healthy  ;  but  they  were  closely 
compressed  by  the  walls  of  the  thorax,  the  transverse  diameter  of 
which  was  very  small.  The  foetal  openings  were  obliterated ;  the 
cerebral  substance  was  healthy ;  yet  there  existed  a  large  quantity 
of  serosity  in  the  lateral  ventricles. 

The  dyspnoea,  and  the  cough  which  accompanied  it  in  this 
child,  therefore  were  the  effect  of  the  little  development  of  the 
thoracic  cavity,  for  there  was  neither  bronchial  catarrh,  nor 
pneumonia,  although  the  existence  of  these  diseases  was  sus- 
pected and  the  patient  treated  accordingly. 

M.  Dupuytren  has  published  an  interesting  essay  on  this  sub- 
ject in  the  fifth  volume  of  the  R&pertoire  general  (VAnatomie. 
He  has  frequently  observed  a  swelling  of  the  tonsils  in  these 
children  which  he  has  even  been  obliged  to  cut  out. 


§  I.  DISEASES  OF    THE  PLEURA,  LUNGS,  AND  BRONCHIA  BEFORE 

BIRTH. 

Diseases  of  the  pleura,  lungs,  and  bronchiae  may  be  separated 


ON   THE    DISEASES    OP    INFANTS.  397 

into  those  which  arise  during  intra-uterine  life,  and  such  as 
manifest  themselves  afterwards. 

Congenital  'pneumonia  and  pleurisy. — Inflammation  of  the 
pleura  and  lungs  may  occur  before  birth.  Some  accoucheurs, 
and  among  others  Mauriceau,  have  given  instances  of  its  occur- 
rence. I  also  have  often  had  opportunities  of  proving  this  fact. 
In  three  children  that  died  on  the  day  after  birth,  I  found  an 
alteration  sufficiently  advanced  to  satisfy  me  that  the  disease  had 
commenced  while  the  child  was  in  the  uterus.  In  two  particu- 
larly, the  left  lung  was  strongly  hepatized  at  the  base ;  and  if 
this  alteration  in  the  tissue  did  not  exist  during  intra-uterine  life, 
it  probably  was  developed  during  birth  or  immediately  after. 
This  affection  always  interferes  with  the  establishment  of  respi- 
ration, and  consequently  causes  the  death  of  the  child.  The 
following  case  is  an  interesting  one  in  reference  to  this  subject. 

CASE  LXIII. — Congenital  pneumonia. — Larche,  born  during  the 
night,  was  placed,  on  the  27th  of  January,  1826,  in  the  "Creche"  of 
the  Hospice  des  Enfans  Trouves.  He  was  sent  immediately  to  the  in- 
firmary, in  consequence  of  his  extreme  feebleness  ;  he  was  small, 
pale,  and  thin  ;  the  face  became  purple  every  moment ;  respiration  was 
slow  and  difficult,  and  the  pulsations  of  the  heart  very  obscure  ;  the 
chest  on  percussion  gave  a  dull  sound.  He  continued  in  the  same 
condition  for  three  days,  and  died  on  the  thirtieth. 

On  a  post  mortem,  examination  the  digestive  apparatus  was  found 
healthy  ;  the  large  intestines  filled  with  meconium  ;  the  left  lung  was 
crepitant  and  slightly  engorged  with  blood  ;  the  right  lung  was  he- 
patized in  almost  all  its  extent ;  there  existed  at  its  base,  a  spot  about 
the  size  of  a  large  nut,  where  the  pulmonary  tissue  was  reduced  to  a 
red  pultaceous  mass  ;  the  bronchiae  were  red  and  thickened,  and 
contained  a  quantity  of  thick  puriform  mucosity,  mixed  with  streaks 
of  blood.  The  heart  was  gorged  with  blood  ;  the  ductus  arteriosus 
was  open,  and  the  foramen  ovale  had  begun  to  close  ;  the  cranium 
was  not  examined. 

It  is  evident  that  this  advanced  disorganization  of  the  lungs 
was  an  effect  of  pneumonia  existing  at  the  time  of  the  birth  of 
the  child.  The  state  of  marasmus,  extreme  feebleness,  and  dif- 
ficulty of  respiration,  were  the  result  of  this  congenital  pneumo- 


398  ON    THE    DISEASES    OF    INFANTS. 

nia,  the  increasing  progress  of  which  arrested  the  first  phenomena 
of  life' 

A  simple  pulmonary  congestion  may  occur  in  an  infant  during 
its  sojourn  in  the  uterus,  and  give  rise,  at  birth,  to  an  impediment 
to  the  introduction  of  air  into  the  lungs,  and  consequently  pre- 
vent the  establishment  of  respiration. 

Pleurisy  may  also  be  developed  before  birth,  as  may  be  seen 
by  the  following  example : 

CASE  LXIV.- — Congenital  pleurisy. — Henriette  Sauvace,  aged, 
two  days,  entered  the  infirmary  on  the  4th  of  October.  She  was 
pale  and  thin,  and  respired  with  great  difficulty ;  the  pulse  was  of  a 
remarkable  irregularity ;  the  expression  of  face  was  every  moment 
very  much  altered ;  the  chest  gave  a  dull  sound  on  the  left  side,  and 
the  air  could  scarcely  be  heard  with  the  stethoscope  to  penetrate  the 
lungs  at  the  superior  part  of  the  thorax.  {Gummed  bariey-water, 
abstinence  from  the  breast.)  On  the  fifth,  the  child  was  in  the  same 
state,  and  on  the  sixth  she  died.  On  opening  the  body,  both  the 
costal  and  pulmonary  pleurce  were  found  spotted,  of  an  obscure  red. 
This  membrane,  particularly  at  the  part  where  it  lines  the  ribs,  ex- 
hibited considerable  thickness,  and  there  existed  between  it  and  that 
of  the  lungs,  cellular  adhesions,  as  solidly  organized  as  they  are  often 
found  to  be  in  adults  eight  or  ten  years  after  the  existence  of  pleurisy. 
The  pleura  also  presented  a  number  of  small  granulations,  and  there 
were  also  adhesions  much  more  recent  than  the  preceding,  for  they 
were  still  of  an  albuminous  consistence.  The  pulmonary  tissue  of 
this  side  was  much  engorged ;  the  foetal  openings  still  existed  ;  the 
brain  presented  nothing  remarkable  ;  in  the  ileo-cajcal  region  there 
were  found  fifteen  very  projecting  dark-colored  follicular  plexuses. 

This  child,  then,  was  born  with  chronic  pleurisy,  which  was 
doubtless  the  cause  of  the  extreme  feebleness,  for  which,  per- 
haps, it  might  have  been  thought  necessary  to  administer  tonics, 
whilst  in  truth  the  first  thing  required  would  be  to  attempt  to 
combat  the  phlegmasia  which  so  quickly  terminated  her  life. 

The  facts  which  I  have  stated  prove  the  possibility  of  an  in- 
fant being  born  with  congenital  pneumonia  or  pleurisy,  and  they 
ought  to  direct  our  attention  to  searching  for  the  causes  of  fee- 
bleness of  birth,  in  order  to  render  the  proper  attention  to  young 
infants. 


ON    THE    DISEASES    OF    INFANTS.  399 

§  II.    DISEASES    OF    THE    LUNGS     AND    PLEURA    DEVELOPED    DU- 
RING   OR    AFTER    BIRTH. 

If  a  disturbance  of  the  functions  of  an  organ  constitutes  a  dis- 
ease, the  difficulty  or  impossibility  of  the  establishment  of  these 
functions  ought  also  to  be  regarded  in  the  same  light.  It  is  not 
only  when  an  anatomical  lesion  or  a  physical  cause,  appreciable 
by  our  senses,  suspends  the  physiological  exercise  of  an  organ, 
that  art  should  be  resorted  to  ;  it  is  sufficient  that  any  obstacle  to 
the  development  of  life  should  exist  in  the  different  parts  of  our 
bodies,  for  us  to  require  assistance  from  the  different  means  which 
science  places  at  our  disposal,  for  the  removal  of  immediate  or 
remote  causes  which  oppose  the  free  development  of  our  func- 
tions. 

The  lungs  of  a  new-born  child,  which,  during  intra-uterine 
^ife,  are  only  organized  in  a  manner  suitable  for  the  reception  into 
their  cells  of  the  air  and  blood  which  are  to  pass  into  them  at 
the  beginning  of  independent  life,  present  to  our  notice,  at  the 
period  of  birth,  phenomena  worthy  of  attention.  For  the  most 
part,  they  at  once  and  without  embarrassment  fulfil  their  new 
functions  ;  at  other  times,  respiration  is  not  established,  and  the 
air  does  not  reach  the  pulmonary  cells.  M.  Capuron  has  re- 
marked, with  much  reason,  that  very  different  states  of  the  cir 
culatory  and  respiratory  apparatus  which  prevent  the  estabhsh 
ment  of  life,  have  been  vaguely  denominated  asphyxia.*  I  will 
designate  then  the  condition  of  new-born  children  now  under 
consideration,  by  the  title  of  imperfect  establishment  of  respira- 
tion. 

The  experiments  of  Haller,  and. those  more  recently  made  by 
Beclardjt  have  demonstrated  that  the  child,  during  its  sojourn  in 
the  uterus,  exercises  in  the  midst  of  the  waters  of  the  amnios 
movements  of  inspiration  and  expiration  ;  of  course  no  air  can 
enter. during  this  first  act  of  the  respiratory  apparatus.  It  is  also 
possible  that  these  movements  continue  after  birth  with  too  little 
energy  for  the  air  to  enter  the  lungs,  either  because  the  cells  of 
this  organ  do  not  dilate,  or  that  the  bronchia^  are  closed  with  mu- 

*  Capuron,  Traitc  des  maladies  des  enfans,  p,  14.         . 
t  Dissertation  inaugurale. 


400  ON   THE    DISEASES    OF    INFANTS. 

cosity,  more  or  less  thick,  adherent  to  their  sides.  Yet  the  child 
may  live  in  this  condition  some  hours,  or  even  days  ;  and  if  the 
lungs  be  examined  after  death,  not  the  least  trace  of  air  will  be 
found  in  them. 

I  have  had  the  opportunity  of  examining  six  infants  who  had 
lived  without  air  having  penetrated  their  lungs  in  sufficient 
quantity  to  prolong  their  lives.  They  were  all  remarkable  for 
extreme  feebleness,  the  slowness  of  their  movements,  the  peculiar 
alteration  of  their  cry,  which  consisted  only  of  an  acute  hiccup 

CASE  LXV. — Three  children  born  at  one  birth,  were  brought  to 
the  Hospice  des  Enfans  Trouves  on  the  21st  of  October,  1826;  the 
smallest,  who  was  a  female,  attracted  my  attention  by  the  slowness 
of  her  movements,  her  sinking  condition,  and  the  peculiar  nature  of 
the  cry,  which  consisted  only  of  an  interrupted  sound  of  the  re- 
prise. The  chest  did  not  rise  or  fall  regularly,  and  gave,  on  per- 
cussion, a  dull  sound  in  all  its  parts  ;  the  stethoscope  did  not  detect 
the  sound  of  respiration.  The  heart  beat  fifty  times  in  a  minute.  A 
few  spoonfuls  of  sweetened  water  were  given  ;  she  was  kept  warm, 
and  dry  frictions  were  applied  to  the  chest ;  the  child,  however,  died 
eight  hours  after  birth. 

The  post  mortem  examination  was  made  the  next  day.  The  um- 
bihcal  cord  was  found  still  soft ;  the  trachea  having  been  tied  at  the 
larynx,  the  heart  and  lungs  were  immersed  in  water ;  they  at  once 
sunk  to  the  bottom  of  the  vessel ;  yet  their  tissue  was  not  engorged ; 
the  right  lung  only  at  its  posterior  border  presented  a  slight  conges- 
tion. Each  lobe  was  then  separated  and  placed  in  water,  and  sunk 
to  the  bottom  with  equal  quickness.  The  heart  was  filled  with 
blood  ;  the  foetal  openings  were  still  free. 

Respiration,  therefore,  was  not  established  in  this  child,  or  at 
least  the  air  had  only  penetrated  to  the  commencement  of  the 
bronchiae.  Death  ensued  not  from  asphyxia,  but  from  defect  in 
the  establishment  of  respiration. 

It  is  not  usual  to  meet  with  so  complete  an  absence  of  air  in 
the  lungs  of  infants,  who,  like  the  one  just  mentioned,  live  for 
some  time,  as  it  were,  the  embryo  life,  either  because  the  blood 
preserves  its  vivifying  principle  which  it  received  from  the  mo- 
ther, or  that  the  oxygen  of  the  air  absorbed  by  the  skin  or  mu- 
cous membranes  penetrated  into  the  circulation,  or  that  this  es 


ON  THE   DISEASES   OF   INFANTS.  401 

sential  element  of  life  is  not  at  this  time  of  so  great  importance  as 
it  is  afterwards.  A  great  portion  of  the  lungs  is  found  destitute 
of  air  in  those  infants  who,  far  from  exhibiting  a  general  conges- 
tion, as  is  the  case  in  true  asphyxia,  present,  on  the  contrary,  an 
excessive  paleness  and  debility.  This  is  the  condition  that  really 
merits  the  name  of  feebleness  of  birth,  and  which  it  is  necessary 
carefully  to  avoid  treating  by  bleeding. 

The  child  ought  to  be  placed  in  such  a  position  as  to  leave  the 
mouth  and  nose  uncovered,  and  in  a  situation  to  receive  a  cur- 
rent of  fresh  air.  Dry  or  aromatic  frictions  should  be  used  on 
the  thorax,  and  care  must  be  taken  to  prevent  the  clothes  from 
being  tight  around  the  thorax  or  abdomen.  The  child  must  be 
fed  with  a  spoon  instead  of  the  breast,  for  sucking  will  be  ex- 
tremely difficult  when  respiration  is  not  completely  established. 

Asphyxia,  properly  so  called,  always  coexists  with  a  greater 
or  less  congestion  of  the  heart  and  large  vessels ;  the  air  some- 
vimes  passes  freely  into  the  lungs  at  the  period  of  birth,  but  the 
sanguineous  congestion  which  occurs  immediately,  expels  it  or 
hinders  it  from  penetrating  in  sufficient  quantity  to  effect  a  com- 
plete establishment  of  life.  There  exists,  as  is  well  known,  be- 
tween the  circulation  and  respiration,  an  intimate  and  reciprocal 
relation,  which  is  evident  during  life,  but  more  particularly  so  at 
the  time  of  birth.  Some  children  are  born  in  so  great  a  state  of 
plethora,  that  all  their  organs,  especially  the  heart,  liver,  and 
lungs,  are  affected  with  congestion  to  a  considerable  degree,  and 
this  congestion  increased  in  the  lungs  by  the  restlessness  and 
cries  of  the  child,  and  perhaps  by  the  respiration  of  heated  air  in 
a  small  room,  warmed  by  a  stove,  the  suspension  of  respiration 
and  a  true  asphyxia  may  follow.  The  face  under  these  circum- 
stances is  usually  purple,  the  pulse  scarcely  perceptible,  and  the 
cry  smothered.  Many  children  born  in  this  condition,  make  at 
first  some  movements  of  inspiration  and  expiration,  utter  some 
sound,  and  remain  in  a  state  of  asphyxia.  Others  are  born  in- 
animate, do  not  respire,  and  the  air  does  not  penetrate  the  lungs 
because  the  air  cells  are  filled  with  blood.  This  state  of  turges- 
ence  occurs  most  often  in  cases  of  difiicult  and  protracted  labor, 
and  the  best  means  to  relieve  it  is  to  allow  the  blood  to  flow  from 
the  umbilical  cord  as  much  as  possible.  The  utility  of  this  pre- 
caution is  so  apparent,  and  so  naturally  occurs  to  the  mind,  that 

51 


402  ON   THE    DISEASES    OP    INFANTS. 

it  has  become  a  daily  practice,  and  on  this  account  hardly  needs 
to  be. recommended  here.  The  custom  of  endeavoring  to  excite 
the  cries  of  the  child  in  order  to  effect  a  movement  of  the  thora- 
cic parietes  and  of  the  lungs,  ought  to  be  condemned  :  for  possi- 
bly during  the  act  of  crying  the  movements  of  the  heart  are 
quicker,  and  the  blood  may  flow  in  great  abundance  towards  the 
lungs.  It  would  be  better,  I  think,  if  this  state  continue,  to  apply 
one  or  two  leeches  to  each  axilla,  and  to  use  cautiously  dry  or 
aromatic  frictions  to  the  thorax.  If  tonic  bathing  is  necessary,  it 
would  be  more  useful  in  the  preceding  case  than  in  true  as- 
phyxia ;  let  us,  therefore,  endeavor  to  distinguish  from  each 
other  the  various  causes  which  oppose  the  establishment  of  re- 
spiration in  new-born  children,  and  only  use  with  discernment 
the  means  proper  for  the  treatment  of  those  effects  which  re- 
sult from  them. 

We  must  not  neglect  to  satisfy  ourselves  that  there  is  not  an 
accumulation  of  serosity  in  ^he  larynx  and  bronchise,  which  will 
become  an  obstacle  to  the  establishment  of  respiration,  and  if  it  be 
found. to  exist,  it  must  be  removed  with  the  fingers  or  a  feather, 
to  effect  a  free  passage  to  the  air  cells. 

Such,  in  general,  are  the  symptoms  which  appear  on  the  part 
of  the  lungs  during  birth  ;  we  shall  now  investigate  the  diseases 
with  which  the  lungs,  bronchise,  and  pleura,  may  be  attacked  af- 
ter birth. 

Art,  1. — Congestions  and  Pulmonary  Apoplexy. 

The  lungs  may,  after  birth,  often  become  the  seat  of  considera- 
ble congestions,  producing  the  most  serious  consequences.  The 
anatomical  characters  of  those  congestions  vary  from  a  simple 
sanguineous  infiltration  to  a  complete  pulmonary  engorgement. 
It  is  difficult  sometimes  to  draw  the  line  between  the  effect  of  a 
congestion,  and  that  produced  by  an  inflammation  in  the  pulmo- 
nary tissue.  Yet  the  following  are  some  of  the  anatomical  char- 
acters of  congestion,  or  pulmonary  engorgement,  in  young  in- 
fants. 

That  the  pulmonary  tissue  which  the  air  has  not  penetrated 
may  not  be  confounded  with  that  which  is  engorged  or  hepatized, 
it  will  be  necessary  to  remember  the  observation  already  made 
of  the  striking  resemblance  between  the  thymus  gland  and  the 


ON   THE    DISEASES    OF    INFANTS.  403 

lungs  of  an  infant  that  has  not  respired.  This  comparison  ought 
to  be  made  in  order  to  assure  ourselves  of  the  state  of  the  lungs 
in  a  post  mortem  examination,  when  it  is  supposed  that  the  child 
has  not  breathed. 

Engorgement  is  more  frequent  at  the  posterior  part  of  the 
lungs,  and  at  the  Hospice  des  Enfans  Trouves  it  is  found  more 
often  in  the  right  than  in  the  left  lung.  The  tissue  of  the  organ 
preserves  its  texture  and  solidity;  it  is  only  infiltrated  with  a 
large  quantity  of  blood,  and  is  easily  deprived  of  its  color  when 
immersed  in  water ;  sometimes  it  happens,  but  not  always,  that 
the  bronchiae,  in  the  midst  of  this  engorged  tissue,  are  red  and 
covered  with  a  sanguineous  exudation.  Pulmonary  engorge- 
ment is  almost  always  accompanied  with  a  sanguineous  conges- 
tion of  the  heart  and  large  vessels,  a  circumstance  which  it  is  ne- 
cessary to  remember  when  we  wish  to  distinguish  engorgement 
from  hepatization  of  the  lungs. 

The  causes  of  engorgement  almost  always  arise  from  some 
disturbance  to  the  course  of  the  blood  through  the  heart  and 
large  vessels.  It  sometimes  continues  for  a  long  time  after  birth, 
and  appears  to  be  the  remote  result  of  a  stagnation  and  super- 
abundance of  blood  in  the  heart  and  lungs  during  birth.  . 

The  symptoms  of  pulmonary  engorgement  in  an  infant  are,  in 
general,  very  obscure,  and  consequently  difficult  of  observation  ; 
yet  we  may  point  out  the  following:  The  respiration  is  labored  ; 
the  thoracic  parietes  are  not  perfectly  developed  ;  the  face  is  pur- 
ple ;  the  general  color  indicates  a  sanguineous  plethora  in  all  the 
organs ;  the  cries  are  obscure,  painful,  and  short ;  percussion 
yields  a  dull  sound,  especially  if,  instead  of  striking  the  anterior 
part  of  the  chest,  the  child  is  exposed,  and,  as  it  were,  suspended, 
by  the  anterior  part  of  the  chest  being  applied  to  the  hand,  while 
small  blows  are  struck  oh  the  back  and  lateral  parts  of  the  tho- 
rax with  the  index  or  middle  finger  of  the  other  hand.  M.  Ba- 
ron uses  this  kind  of  percussion  with  great  skilfulness  ;  the  faci- 
lity he  has  acquired  of  distinguishing  the  different  sounds  in  the 
chest,  enables  him  often  to  make  very  accurate  diagnosis  on  the 
diseases  of  the  thorax  in  very  young  infants.  The  importance 
of  this  species  of  examination  cannot  be  too  much  impressed  on 
the  minds  of  practitioners,  for  in  infancy  it  is  much  more  useful 


404  ON    THE    DISEASES    OP    INFANTS. 

than  mediate  auscultation,  especially  when  there  exists  a  sim- 
ple pulmonary  engorgement. 

The  treatment  of  this  affection  being  the  same  as  that  of  pneu- 
monia, of  which  it  is  often  the  first  stage,  we  must  refer  to  the 
history  of  that  disease  for  the  necessary  details  of  the  manage- 
ment. 

Pulmonary  congestion  or  engorgement  may  be  the  cause  of  se- 
veral affections  or  lesions  in  the  tissue  of  the  lungs,  but  more 
especially  of  pulmonary  apoplexy. 

Pulmonary  apoplexy. — This  is  of  more  common  occurrence 
in  new-born  children  than  in  adults  or  old  people ;  the  frequen 
cy  of  congestion  of  the  lungs  at  this  period  of  life,  satisfactorily 
explains  this  fact.  It  consists  of  an  effusion  of  blood  circum- 
scribed in  the  middle  of  the  tissue  of  the  lungs ;  it  may  occur 
suddenly  or  slowly,  according  to  the  abundance  of  blood  flowing 
towards  the  organ  and  the  intensity  of  the  cause  which  deter- 
mines this  afflux.  This  disease,  first  pointed  out  by  Laennec, 
has  since  been  described  by  M.  Gendrin  and  M.  Bouillaud,  who 
have  published  some  interesting  observations  on  the  subject.*  I 
have  often  met  with  it  in  young  infants,  and  M.  Denis  has  also 
mentioned  it  in  his  work.     I  will  here  give  some  cases  of  it. 

CASE  LXVI. — Francoise  Redon,  aged  three  days,  entered  the  in- 
firmary on  the  20th  of  April,  for  a  diarrhoea  accompanied  with  icte- 
rus diffused  over  the  whole  body.  On  the  twenty-sixth,  the  child 
became  very  feeble,  and  passed  an  abundance  of  green  matters  from 
the  bowels.  On  the  twenty-eighth,  he  vomited  the  drinks  ;  the  cry 
was  smothered,  and  the  chest  was  sonorous  only  on  its  right  side. 
On  the  3d  of  May,  the  same  general  state  continued,  but  the  face  was 
puffed,  and  the  icterus  had  disappeared;  death  occurred  at  night. 
The  internal  membrane  of  the  glottis  was  found  intensely  red,  with 
a  slight  pellicular  exudation.  The  right  lung  was  crepitant;  the  left 
was  so  at  its  circumference  ;  but  in  the  centre  of  its  tissue  there  were 
found  three  small  circumscribed  sanguineous  effusions ;  the  pulmo- 
nary tissue  was  hard,  and,  as  it  were,  hepatized  at  its  circumference. 

CASE  LXVII. — Auguste  Bonnet,  aged  two  days,  had  not  ceased 

♦  Observations  four  scrvir  d  Vhistoirc  de  Vapoplexie  pulmonaire,  by  J.  Bouillaud, 
Archives  gen6ral«s  de  med.,  1826. 


ON   THE    DISEASES    OP    INFANTS.  405 

crying  since  his  birth  ;  he  was  feeble  and  small,  and  affected  with 
icterus ;  the  temperature  of  the  body  was  very  low  ;  at  every  mo- 
ment he  was  seized  with  suffocation,  which  threatened  his  death  ;  the 
face  became  purple  and  puffed ;  the  cry  was  almost  entirely  stifled  ; 
the  pulsations  of  the  heart  were  tumultuous  and  irregular  ;  respiration 
could  not  be  heard  except  at  the  upper  part  of  the  thorax,  and  it 
gave,  on  percussion,  a  dull  sound  in  almost  every  part ;  the  same 
state  continued  until  the  3d  of  October,  when  the  child  died  while 
vomiting  frothy  and  bloody  matters. 

Post  mortem  examination. — Extensive  congestion  of  the  base  of 
the  tongue  and  thyroid  gland  ;  the  same  condition  of  the  oesophagus  ; 
a  well-marked  injection  of  the  intestinal  tube,  which  was  covered  in- 
teriorly with  thick  mucosity  ;  the  liver  was  gorged  with  blood  ;  the 
bile  was  clear  and  not  very  abundant ;  the  left  lung  was  crepitant, 
although  infiltrated  with  a  quantity  of  blood  ;  the  right  lung  appear- 
ed black  externally  ;  when  immersed  in  water  it  soon  sunk  to  the 
bottom  of  the  vessel,  and  when  cut  a  large  quantity  of  blood  was 
found  effused  in  clots,  and  separated  by  intervals  where  the  tissue  of 
the  lungs  did  not  crepitate,  and  consequently  appeared  not  to  have 
been  penetrated  by  air  ;  the  foramen  ovale  was  obliterated,  and  the 
ductus  arteriosus  was  still  open  ;  the  bronchiae  were  full  of  bloody 
mucosity,  which  even  extended  to  the  trachea  and  larynx ;  there  was 
but  little  serosity  in  the  ventricles  of  the  brain,  the  substance  of 
which  was  yellow  and  a  little  softened. 

It  is  evident  that,  in  these  two  cases,  the  suffocation,  the  gene- 
ral condition  of  the  children,  the  alteration  of  the  cry,  the  swell- 
ing and  purple  color  of  the  face,  and  finally  death,  were  caused 
by  the  sanguineous  effusion  in  the  pulmonary  tissue,  which  the 
air  had  with  difiiculty  penetrated.  In  a  third  child  exhibiting 
the  same  symptoms,  aged  ten  days,  I  found  a  much  greater  lesion 
in  the  pulmonary  tissue,  for  in  the  right  lung  there  appeared  two 
large  spots  of  black  liquid  blood,  around  which  the  pulmonary 
tissue  had  begun  to  soften ;  the  foetal  openings  were  still  free,  and 
the  right  cavities  of  the  heart  were  more  dilated  than  the  left ; 
the  brain  v/as  much  engorged  with  blood. 

We  may  therefore  conclude  from  the  preceding  facts,  that  pul- 
monary appoplexy  may  succeed  congestion  of  the  lungs,  or  may 
accompany  this  condition  ;  that  the  most  prominent  symptom  is 
a  suflfocating  cry ;  that  percussion  indicates  the  absence  of  air  in 


406  ON  THE    DISEASES   OP   INFANTS. 

the  affected  lung,  and  that  there  is  sometimes  an  expulsion  of 
bloody  miicosity. 

The  first  indication  to  be  fulfilled  is  the  abstraction  of  blood, 
which  can  best  be  done  by  the  application  of  one  or  two  leeches 
under  each  axilla ;  the  subcutaneous  venous  plexuses  in  this 
region  communicate  directly  with  the  vessels  of  the  thoracic  ca- 
vityj  and  are  thus  convenient  for  the  sudden  evacuation  of  blood 
from  the  affected  part.  It  is  of  the  greatest  importance  to  avoid 
clothing  too  tightly  a  child  that  presents  these  symptoms,  either 
at  birth  or  at  a  more  advadced  age,  for  by  impeding  the  dilata- 
tion of  the  thorax,  there  is  danger  of  augmenting  the  congestion. 
As  to  other  and  subsequent  treatment,  they  will  be  found  under 
the  head  of  pneumonia. 

Art.  2. — Pneumonia. 

Pneumonia  of  infants  exhibits  peculiar  characters,  in  which  it 
differs  from  the  same  affection  in  adults.  Instead  of  being  an 
idiopathic  affection,  arising  from  irritation  developed  in  the  pul- 
monary tissue  under  the  influence  of  atmospheric  causes,  which 
often  excite  this  disease,  the  pneumonia  of  young  infants  is  evi- 
dently the  result  of  a  stagnation  of  blood  in  their  lungs.  Under 
these  circumstances,  this  blood  may  be  regarded  as  a  kind  of  for- 
eign body,  and  it  concurs  in  producing  an  alteration  in  the  pul- 
monary tissue  with  which  it  combines,  and  is  identified  with  it 
so  as  to  form  what  is  called  a  hepatization  of  the  lungs.  In  proof 
of  this,  it  is  known  that  pneumonia  almost  always  follows  con- 
gestion or  engorgement  of  the  lungs,  and  as  this  engorgement  is 
more  frequent  in  the  right  lung  than  in  the  left,  and  at  the  poste- 
rior border  of  the  lungs  than  in  any  other  part  of  the  organ, 
pneumonia  appears  much  more  frequently  in  the  right  than  left 
lung  ;  at  least  it  is  so  with  respect  to  the  children  which  I  have 
examined  at  the  Hospice  des  Enfans  Trouves,  who  are  always 
placed  at  rest  on  the  right  side.  It  would  therefore  appear  that 
inflammation  of  the  lungs  which  produces  hepatization,  arises,  in 
infants  in  general,  from  some  mechanical  or  physical  cause, 
whilst  this  is  not  the  case  in  adults ;  besides,  the  inflammation  of 
the  lungs  is  ordinarily  very  circumscribed,  and  is  found  almost 
always  confined  to  a  point  primarily  engorged,  and  the  pleura, 


ON   THE    DISEASES    OF    INFANTS.  407 

which,,  in  the  greatest  number  of  instances,  is  inflamed  at  the 
same  time  with  the  lungs,  at  a  more  advanced  age,  is  not  affect- 
ed in  young  infants. 

The  inflammation,  once  developed,,  may  give  rise  to  various 
alterations  of  tissue,  the  shades  and  diflerent  degrees  of  which 
vary  from  simple  hepatization  to  a  great  disorganization  of  parts. 
We  will  commence  by  detailing  cases. 

CASE  LXVIII. — Emilie  Tavenne,  aged  five  days,  entered  the  in- 
firmary on  the  20th  of  September ;  she  was  small  and  feeble ;  the 
integuments  were  very  red ;  had  a  diarrhcea  of  yellov/  and  green 
matters  ;  the  cry  was  feeble,  and  at  times  could  scarcely  be  heard. 
{Gummed  rice  icater,  starch  injection,  milk  and  water.)  On  the 
twenty-second,  the  face  became  livid,  and  expressive  of  pain ;  the 
alae  of  the  nose  were  drawn  outward,  and  they  were  surrounded 
with  a  violet-colored  circle ;  the  cry  was  painful,  and  almost  always 
husky ;  the  thorax  gave  a  dull  sound  on  the  right  side,  where  respi- 
ration could  not  be  heard.  (Gummed  decoction  of  marshmallows, 
sinapised  pedeluvium.)  On  the  twenty-third,  there  appeared  to  be 
no  febrile  reaction ;  the  limbs  were  cold  and  oedematous  ;  the  pulsa- 
tions of  the  heart  were  so  obscure  that  it  was  impossible  to  count 
them.  The  child  died  on  the  twenty-fourth.  On  opening  the  body, 
red  streaks  were  found  in  the  stomach  and  at  the  commencement 
of  the  small  intestine,  and  fifteen  follicular  plexuses,  red  and  tume- 
fied, at  the  inferior  portion  of  the  ileon.  The  commencement  of  he- 
patization appeared  in  the  left  lung  at  its  superior  lobe ;  the  right 
lung  was  hepatized  throughout  its  whole  extent ;  its  pieces,  when 
cut,  did  not  present  a  true  cellular  texture,  and  sunk  rapidly  to 
the  bottom  of  the  water ;  the  pleura  was  perfectly  healthy ;  the  foetal 
openmgs  were  obliterated ;  the  bronchiae  were  red  and  filled  with 
blood  ;  the  brain  and  meninges  were  very  much  injected. 

It  will  be  observed  that  there  was  no  symptom  of  reaction  in 
this  child,  but  the  local  symptoms  were  very  well  defined,  and 
not  severe.  It  is  then  to  the  latter,  that  the  physician  ought  to 
direct  his  attention  in  order  to  make  a  correct  diagfnosis  of  the 
disease.  The  subject  of  the  following  case  was  more  advanced 
in  age,  and  the  symptoms  present  a  new  character,  which  are  to 
be  attributed  to  the  modifications  which  age  produces  in  the 
organization. 


408  ON    THE    DISEASES    OP    INFANTS. 

CASE  LXIX. — Josephine  Oudon,  aged  seven  months,  entered 
the  infirmary  on  the  8th  of  June,  for  a  gastro-intestinal  inflammation 
developed  five  days  after  having  been  vaccinated,  which  however 
yielded  to  the  application  of  three  leeches  to  the  epigastrium,  bath- 
ing, and  demulcent  drinks.  While  convalescent  from  this  disease,  she 
was  on  the  twenty-second  of  June,  suddenly  attacked  with  a  frequent 
dry  cough,  accompanied  with  great  restlessness.  There  occurred  at 
the  same  time  an  intense  redness  on  the  left  cheek  ;  the  skin  was 
burning  ;  the  pulse  very  frequent ;  respiration  laborious,  without  any 
rale  ;  the  cry  which  was  constantly  husky,  became  stifled  whenever 
the  child  had  cried  much ;  the  face  changed  color,  became  pinched, 
and  appeared  also  to  swell  and  to  become  purple  whenever  the  child 
began  to  cry.  ( Three  leeches  to  the  upper  and  lateral  parts  of  the 
thorax^  gummed  barley-water.)  The  leech-bites  bled  copiously,  and 
produced  syncope.  On  the  twenty-eighth,  blood  oozed  from  the  left 
eye.  In  the  evening  of  the  1st  of  July,  there  supervened  fever  and 
restlessness,  accompanied  with  a  slight  cough,  without  expectoration ; 
there  exis4,ed  no  rale  ;  the  thorax  was  dull  on  the  left  side.  From 
this  time  to  the  10th  of  July,  the  same  symptoms  continued ;  the 
child  gradually  sunk ;  the  pulse  became  threadlike  and  very  fre- 
quent ;  and  the  face  was  covered  with  petechial  spots  which  con- 
tinued several  days.  The  same  state  continued  until  the  period  of 
death,  which  took  place  on  the  eighteenth. 

Post  mortem  examination. — There  was  great  emaciation  and  uni- 
versal paleness ;  the  stomach  was  colorless,  but  without  being  soft- 
ened ;  six  follicular  plexuses,  of  a  very  intense  red,  were  found  at  the 
extremity  of  the  ileon,  which  was  also  very  much  injected  to  the 
extent  of  eight  inches;  the  right  lung  was  hepatized  at  the  posterior 
border,  and  the  whole  of  the  inferior  lobe  of  the  left  lung  was  in  the 
same  state.  It  presented  a  smooth  surface  when  cut,  and  the  pieces 
which  were  not  cellular,  and  which  could  be  pressed  between  the 
fingers  without  yielding  any  blood,  fell  like  a  stone  to  the  bottom  of 
the  water.  The  bronchial  ramifications  were  filled  with  slightly  red 
and  frothy  mucus  ;  the  trachea  was  healthy ;  the  heart  and  brain 
presented  nothing  remarkable. 


We  have  seen  in  this  child  not  only  the  local  symptoms  of 
pneumonia,  but  also  those  which  ordinarily  produce  febrile  re- 
action occasioned  by  phlegmsiae  of  the  principal  viscera.  Cough, 
which  was  absent  in  the  former  case,  was  in  this  added  to  the 


ON   THE    DISEASES    OP    INFANTS.  409 

Other  symptoms ;  but,  as  in  the  other  instance,  there  was  no  ex- 
pectoration, which  indeed  is  impossible,  or  at  least  very  difficult 
in  young  children  ;  they  vomit  much  sooner  than  they  expecto- 
rate, a  phenomenon  produced  almost  always  by  the  sudden 
action  of  the  diaphragm  on  the  stomach,  on  coughing.  The  ex- 
amination of  the  organs  also  enables  us  to  discover  nothing  more 
than  simple  pneumonia,  without  the  complication  of  pleurisy, 
which,  I  repeat,  is  very  common  in  young  infants. 

Abscesses  in  the  lungs  caused  by  pneumonia  is  very  rare  in 
adults,  where  suppuration  is  not  usually  observed  to  exist,  in  a 
circumscribed  spot  or  focus,  but  disseminated  and  infiltrated  in 
the  tissue  of  that  organ  ;  pulmonary  abscess  is  equally  rare  in 
infants  ;  yet  they  may  occur,  as  may  be  seen  by  the  following 
case. 

CASE  LXX. — Theophile  Champion,  aged  three  months,  had 
been  twice  in  the  hospital  since  birth :  the  first  time  for  an  cedema 
of  the  limbs ;  the  second  for  enteritis  with  green  diarrhoea,  compli- 
cated with  a  cough.  These  symptoms,  however,  yielded  to  simple 
means,  and  the  child  was  confided  to  the  care  of  the  ordinary 
nurses ;  but  on  the  2d  of  March,  he  entered  the  infirmary  for  the 
third  time.  He  was  pale  and  very  thin.  There  was  no  diarrhoea ; 
the  abdomen  was  tympanitic,  but  without  pain.  He  was  affected 
with  constant  cough,  and  the  respiration  was  loud ;  the  thorax  re- 
sounded badly  throughout,  although  it  did  not  give  a  positive  dull 
sound  in  any  part.  (Sweetened  barley-water,  milk  and  water.)  On 
the  10th  of  March,  he  appeared  to  be  much  better,  or  at  least  the  re- 
spiration was  more  free ;  the  cough  however  continued,  although  he 
had  no  fever ;  on  this  apparent  improvement,  the  nurse  took  charge 
of  him ;  but  the  cough  returned  the  same  night,  accompanied  with 
suffocation,  and  the  cries  of  the  child,  which  could  be  heard  only  for 
a  moment,  expressed  the  greatness  of  the  suffering.  He  re-entered 
the  infirmary  at  eleven  in  the  morning  ;  the  cough  was  frequent  and 
dry,  the  face  purple,  the  alae  of  the  nose  drawn  outward,  and  were 
surrounded  by  a  blue  circle,  which  was  also  observed  at  the  root  of 
the  nose  ;  the  cry  was  plaintive  and  distressing ;  the  left  side  of  the 
thorax  gave  a  dull  sound,  and  the  respiration  could  not  be  heard ; 
the  limbs  were  cold  and  the  pulse  small  and  irregular.  (Milk  and 
water,  sinapism  to  the  feet.)     On  the  thirteenth,  the  eyes  became 

hollow ;  the  respiration  was  hurried,  and  the  other  symptoms  con- 

52 


410  ON   THE    DISEASES   OF   INFANTS. 

tinued  the  same.  The  same  condition  continued  until  the  sixteenth, 
when  death  occurred  towards  evening. 

Post  mortem  examination. — The  stomach  showed  a  white  soften- 
ing in  its  whole  extent,  and  near  the  cardia  exhibited  several  super- 
ficial erosions.  The  same  state  existed  throughout  the  whole  ex- 
tent of  the  intestinal  tube,  which  was  covered  with  yellow  porraceous 
matters.  The  liver  was  healthy,  but  the  gall-bladder  was  filled  with 
black  viscid  bile. 

At  the  base  of  the  left  lung,  there  was  a  collection  of  pus  about 
the  size  of  a  filbert,  white  and  thick,  but  without  odor  ;  the  internal 
surface  of  the  cavity  containing  this  pus,  was  even  and  red,  but  did 
not  appear  like  a  cyst.  The  right  lung  was  healthy ;  the  fcetal  open- 
ings were  obliterated ;  the  brain  was  healthy,  but  the  meninges  were 
injected. 

We  have  reason  to  think  that  this  child  had  been  affected  with 
pneumonia  for  a  long  time,  with  symptoms  obscure,  it  is  true, 
but  which  were  sufficient  to  fix  the  attention  of  the  physician ; 
the  nurses  who  only  observed  in  this  infant  the  paleness  and  de- 
bility, withdrew  him  from  the  care  and  attention  of  the  physician, 
when  they  discovered  what  they  believed  to  be  a  melioration  of 
the  symptoms,  which  could  only  deceive  persons  unaccustomed, 
as  they  were,  to  the  art  of  observing  the  sick.  The  inflamma- 
tion had  made  a  slow  but  steady  progress  until  suppuration  oc- 
curred in  the  affected  organ.  This  case  proves  how  necessary 
it  is  to  be  constantly  on  our  guard  in  cases  of  obscure  phlegma- 
sise,  which  in  infants,  much  more  often  than  in  adults,  may 
produce  the  most  serious  lesions  without  a  suspicion  of  such  an 
event  on  the  part  of  the  physician. 

I  have  seen  in  the  dead  body  of  an  infant,  aged  twenty 
days,  that  died  without  exhibiting  any  evident  symptoms  of 
pneumonia,  the  right  lung  hepatized  in  almost  its  whole  ex- 
tent, together  with  three  white,  soft,  and  elastic  projections  on 
the  base  of  this  lung  and  on  its  middle  lobe,  which  on  being 
opened  discharged  a  quantity  of  air,  and  immediately  collapsed. 
They  were  formed  by  a  very  thin  cyst,  which  contained  white, 
inodorous,  thick,  and  stringy  pus.  The  internal  surface  of 
these  cysts  was  red  and  granulated ;  it  was  confounded  posteri- 
orly with  the  tissue  of  the  lungs.  The  bronchiae  did  not  open 
into  them :  they  were  inflamed,  and  small  drops  of  pus,  like  that 


ON   THE    DISEASES    OF    INFANTS.  411 

just  described,  oozed  out  on  pressure.  The  other  organs  pre- 
sented nothing  remarkable. 

It  is  evident  that  this  suppuration  of  the  bronchiag,  and  the 
abscess  of  the  hing,  were  the  result  of  a  latent  phlegmasia,  the 
symptoms  of  which  had  escaped  my  observation,  not  having 
bestowed  sufficient  attention  for  that  purpose. 

Inflammation  of  the  lungs  may  not  only  produce  hepatization 
and  suppuration,  but  also  its  softening  or  disorganization,  which 
is  noticed  also  to  arise  under  the  influence  of  inflammation  in 
other  organs. 

CASE  LXXI. — Rony  was  exposed  immediately  after  birth,  on  the 
7th  of  February,  at  the  Hospice  des  Enfans  Trouves.  He  was  im- 
mediately placed  under  the  care  of  a  nurse,  and  took  the  breast  with 
eagerness  ;  he  soon  stopped  sucking,  because  he  appeared  to  become 
smothered  every  instant ;  the  face  became  purple ;  he  attempted  to 
cry,  without  being  able  to  do  so.  He  was  fed  with  a  spoon.  This 
condition  continued  the  same,  but  in  addition  to  the  other  symptoms, 
he  vomited  almost  continually ;  had  a  smothered  cry  ;  the  stools 
were  natural.  Death  occurred  on  the  eleventh.  As  this  child  was  not 
sent  to  the  infirmary,  I  was  unable  to  observe  him  very  closely,  but 
it  was  from  the  relation  of  the  nurse  that  I  obtained  the  foregoing 
account.  On  examining  the  body  after  death,  I  noticed  the  com- 
mencement of  the  discoloration  of  the  mucous  membrane  of  the  in- 
testines ;  the  heart,  liver,  and  large  vessels  were  filled  with  blood ; 
the  left  lung  was  considerably  filled  with  blood  at  its  posterior  bor- 
der, which  was  found  in  a  state  approximating  to  hepatization,  while 
the  remainder  was  reduced  to  a  reddish,  diffluent,  soft  mass.  This 
mass  yielded  no  odor  of  sulphuretted  hydrogen,  and  when  diluted 
with  water  exhibited  grayish  pulpy  clots,  which  appeared  to  be  the 
effect  of  the  disorganization  of  the  lungs.  The  bronchiae  were  a 
little  more  red  in  their  remote  branches ;  they  were  healthy  and 
white  where  they  first  diverge.  The  right  lung  was  simply  en 
gorged. 

This  disorganization  of  tissue  appeared  to  me  to  be  the  result 
of  pneumonia,  which,  perhaps,  had  succeeded  a  passive  conges- 
tion, as  is  often  observed  in  new-born  children.  Whatever  may 
be  the  cause,  it  should  convince  us  of  the  necessity  and  impor- 
tance of  observing  the  symptoms  of  pneumonia  in  young  infants, 


412  ON   THE    DISEASES   OP    INFANTS. 

since  this  disease  may,  even  at  this  age,  be  followed  with  fatal 
effects. 

Before  exhibiting  the  general  assemblage  of  symptoms  of 
pneumonia,  let  us  study  the  disease  as  complicated  with 
pleurisy. 

Pleuro-pneumonia. — I  have  already  remarked  that  this  was 
much  more  rare  in  infants  than  in  adults.  It  is  principally  in 
children  that  are  somewhat  advanced  in  age,  that  it  is  to  be 
found  ;  the  disease  is  then,  not  the  effect  of  pulmonary  conges- 
tion, as  in  simple  pneumonia  of  new-born  children,  but  is  the 
result  of  the  direct  or  remote  action  of  the  atmosphere,  or  of  other 
external  causes. 

CASE  LXXII. — Pleuro-pneumonia. — Honore  Lucet,  aged  five 
months,  entered  the  infirmary  on  the  5th  of  May.  He  had  already 
a  month  previous  been  admitted  for  enteritis,  which  had  been  cured. 
He  nevertheless  continued  pale  and  thin.  He  was  now  affected  with 
considerable  tension  of  the  abdomen,  and  vomited  all  his  drinks : 
the  respiration  was  labored  ;  but  the  cry  exhibited  no  alteration,  but 
had  become  weakened  by  its  frequency.  On  the  sixth,  the  face  as- 
sumed a  painful  expression,  and  from  being  habitually  pale,  became 
livid  ;  the  vomiting  did  not  cease.  On  the  seventh,  there  was  great 
restlessness  ;  the  limbs  became  stiff,  and  remained  in  a  state  of  spasm ; 
the  cries  could  scarcely  be  heard  ;  the  chest  gave  a  dull  sound  oil  the 
right  side,  but  resounded  well  on  the  left ;  the  pulse  was  slow  in  the 
morning,  but  in  the  evening  it  rose  to  one  hundred  and  forty  beats  in 
a  minute ;  a  general  sweat  supervened,  and  the  limbs,  which  during 
the  day  had  remained  contracted,  again  became  flexible.  (Milk  and 
water,  four  leeches  to  the  leftside  of  the  chest.)  On  the  eighth  and 
ninth,  there  was  a  slight  melioration  of  symptoms,  for  the  cries  and 
restlessness  of  the  child  were  less  violent ;  but  on  the  tenth,  all  the 
symptoms  returned,  and  the  face  bore  the  expression  of  extreme 
suffering.  On  the  eleventh,  a  layer  of  muguet  appeared  on  the  buc- 
cal parietes,  and  on  the  twelfth,  the  child  expired. 

Post  mortem  examination. — There  was  a  white  softening  of  the 
whole  of  the  intestinal  mucous  membrane,  redness  of  the  glottis,  a 
healthy  state  of  the  trachea,  and  a  hepatization  of  the  right  lung  in 
its  entire  extent.  Between  the  two  pleura?  of  this  side,  there  were 
adhesions  which  already  possessed  some  degree  of  firmness ;  there 
was  but  a  small  quantity  of  sero-purulent  fluid  effused  in  the  cavity 


ON   THE    DISEASES    OP    INFANTS.  413 

of  the  thorax ;  a  part  of  the  right  lung  was  of  a  gray  slate-color ;  in 
the  centre  there  appeared  a  reddish  softening,  and  the  bronchiae  of 
this  lobe  alone  contained  puriform  mucosity ;  the  brain  was  healthy, 
and  when  cut,  exhibited  a  smooth,  firm  surface ;  neither  the  spina,! 
marrow  nor  the  meninges  exhibited  any  appreciable  alteration. 

This  child,  with  the  exception  of  the  excessive  pain  which 
he  had  experienced,  and  of  which  the  contraction  of  the  limbs 
was  perhaps  the  secondary  effect,  exhibited  no  other  symptom 
than  those  of  pneumonia;  so  that  it  seems  to  me  very  difficult 
to  distinguish  pneumonia  from  pleuro-pneumonia  in  very  young 
infants.  This  distinction,  however,  is  not  of  much  utility,  since 
the  treatment  of  the  one  is  perfectly  applicable  to  the  other. 

We  are  now  able  to  recapitulate  the  symptoms  of  pneumonia 
and  pleuro-pneumonia  in  children  at  the  breast. 

Respiration  is  laborious,  short,  painful,  and  cannot  be  heard 
by  auscultation  in  the  portion  of  the  lung,  or  in  the  lung  that  is 
hepatized ;  the  chest  gives  a  dull  sound  on  percussion  ;  breathing 
is  sometimes  suffocating,  and  the  rale  is  not  always  heard. 

The  cry  is  incomplete,  and  almost  always  smothered;  be- 
coming clear  for  a  moment,  and  returning  afterwards  to  the 
alteration  in  the  tone  which  we  have  mentioned.  The  reprise 
usually  exists,  and  it  is  more  particularly  the  cry  which  is  want- 
ing, or  which  is  not  heard  as  in  the  natural  state. 

Cough  is  sometimes  present,  but  this  is  not  always  the  case, 
and  demands  but  a  secondary  attention. 

Expectoration  does  not  exist,  and  cannot  here,  as  in  adults, 
enlighten  us  as  to  the  nature,  seat,  and  stage  of  pulmonary  phleg- 
masia ;  the  same  may  be  observed  with  regard  to  pain  in  the 
side.     Bloody  vomiting  is  rare. 

The  peculiar  expression  of  the  face  in  diseases  of  the  chest 
consists  in  a  drawing  of  the  alae  of  the  nose  outward,  and  which 
the  child  appears  to  dilate  with  great  effort,  and  more  especially 
in  a  blue  circle  around  the  lower  part  of  the  nose  and  commissure 
of  the  mouth,  and  which  is  doubtless  the  result  of  a  great  dis- 
turbance in  the  general  or  capillary  circulation.  Those  wrin- 
kles on  the  forehead  which  are  to  be  observed  in  abdominal 
affections,  less  frequently  exist.  Yet  the  nasal  and  the  genal 
lineaments  are  frequently  observed ;  the  face  sometimes  becomes 


414  ON   THE    DISEASES    OF    INFANTS. 

oedematousj  particularly  at  the  termination  of  the  disease.  Fe- 
brile re-action  scarcely,  if  ever,  occurs  in  very  young  infants, 
but  appears  in  proportion  as  the  child  advances  in  age ;  the 
pulse  is  often  small  and  obscure,  the  skin  cold  and  livid,  and 
the  limbs  are  oedematous. 

As  pneumonia  is  developed  very  often  after  pulmonary  con- 
gestion, and  as  the  latter  occurs  in  strong  children,  that  are 
plethoric,  the  patient  affected  with  pneumonia  has  often  a  high 
color,  and  is  swelled  or  oedematous.  If  the  disease  continues 
for  some  time,  a  state  of  marasmus  ensues,  which  is  common  to 
chronic  phlegmasise  in  general. 

Such  are  the  most  common  symptoms  of  pneumonia  in  chil- 
dren at  the  breast.  It  can  easily  be  conceived,  however,  that 
they  may  offer  several  modifications  in  different  infants,  and 
especially  at  different  ages,  and  which  can  only  be  learned  by 
close  observation  of  the  sick. 

Treatment. — Children  affected  with  pulmonary  congestion  or 
pneumonia  ought,  in  the  first  place,  to  have  all  tight  clothing 
removed.  Immediately  upon  the  appearance  of  symptoms  of 
pulmonary  congestion,  two,  four,  or  six  leeches,  according  to  the 
strength  of  the  child,  ought  to  be  applied  to  the  base  of  the  chest, 
or  under  each  axilla.  The  child  should  not  be  placed  in  a  warm 
bath,  because  the  heat  and  pressure  of  the  fluid  will  augment 
the  afflux  of  blood  towards  the  thorax,  and  increase  the  labor  of 
respiration.  The  child  must  be  kept  from  the  breast  for  twenty- 
four  or  twenty-eight  hours,  giving  in  its  place  some  milk  and 
water,  or  milk  of  almonds.  If  the  inflammation  continue  after 
sanguineous  evacuations,  recourse  must  be  had  to  dry  cupping 
on  the  thorax,  or  to  irritation  or  blistering  either  to  the  chest  or 
arms.  Revulsives  to  the  extremities  or  to  the  intestinal  tube 
may  be  employed  to  diminish  the  difficulty  of  breathing.  If  the 
pain  be  excessive,  producing  continual  restlessness  and  crying, 
it  will  be  advantageous  to  give  a  small  quantity  of  syrup  of  pop- 
pies in  two  ounces  of  linctus.  Anatomical  researches  have 
proved  that  pneumonia  in  young  infants  is  always  the  result  of 
sanguineous  congestion;  that  it  is  purely  local,  and  that  often 
the  bronchiae  do  not  participate  in  the  inflammation.  Conse- 
quently there  can  be  but  little  benefit  derived  from  the  use  of 
syrup  of  ipecacuanha,  kermes  mineral,  or  even  of  squills,  usually 


ON   THE   DISEASES   OP   INFANTS.  415 

given  in  these  affections,  in  order  to  produce  an  expulsion  of 
mucosity.  Besides,  it  is  well  known  that  in  new-born  children 
there  is  no  expectoration.  Under  the  supposition,  then,  that 
these  medicines  excite  the  bronchiae,  the  child  may  by  their  use 
be  teased  with  desires  which  it  cannot  gratify.  But  at  a  more 
advanced  age,  and  when  there  exist  symptoms  of  bronchitis, 
there  may  be  given  with  advantage,  particularly  in  the  latter 
period  of  the  disease,  half  a  grain  of  kermes  mineral  in  two  or 
three  ounces  of  water,  by  the  tea-spoonful.  M.  Duges,  who  has 
given  some  excellent  precepts  on  the  treatment  of  pneumonia, 
advises  the  use  of  a  mixture,  made  with  two  drachms  of  oxymel 
of  squills,  and  an  ounce  of  gum  syrup  and  orange-flower  water. 
We  should  be  careful  not  to  administer  syrup  of  ipecacuanha  in 
every  instance  in  which  a  child  coughs,  without  ascertaining  the 
nature  of  the  cough,  together  with  the  local  or  general  symptoms 
which  exist  at  the  same  time.  In  the  use  of  medicines  in  gene- 
ral, we  must  not  lose  sight  of  the  importance,  while  meeting  the 
symptoms,  of  considering  the  nature,  seat,  and  modifications  of 
the  various  lesions  which  produce  them. 

If  the  child  continue  debilitated,  after  an  attack  of  pneumonia, 
if  for  a  long  time  it  experience  a  disordered  state  of  the  system, 
which  appears  to  arise  from  the  remnant  of  irritation  in  the 
thoracic  organs,  it  will  be  necessary  to  use  the  most  assiduous 
care  to  prevent  a  return,  by  covering  the  skin  with  flannel,  by 
removing  it  from  all  the  causes  capable  of  exciting  afresh  the 
respiratory  apparatus,  such  as  too  frequent  cries,  the  exposure 
of  the  child  to  cold  air  or  violent  wind ;  by  walks,  or  by  a  resi- 
dence in  humid  places,  as  valleys,  or  the  bank  of  a  river,  etc. 
We  should  remember  that  this  is  a  period  of  life  at  which  the 
different  organs  are  susceptible  in  their  progress  of  development, 
of  acquiring  certain  modifications  which  dispose  them  to  idiosyn- 
cracies,  the  influence  of  which  may  remain  during  life.  How 
often  do  we  see  children  born  with  all  the  appearances  of  flour- 
ishing health,  almost  always  become  feeble  and  sickly  from  dis- 
eases which  attacking  them  in  their  early  infancy,  leave  after  them 
vital  or  organic  modifications  which  time  can  scarcely  remove, 
and  which  in  some  individuals  never  disappear!  Far  be  it  from 
me  to  yield  to  ridiculous  prejudices;  but  without  admitting 
the  remains  of  measles,  hooping-cough,  or  thoracic  eflfusions. 


416  ON   THE    DISEASES    OF    INFANTS. 

lo  which  a  thousand  distressing  symptoms  are  vulgarly  attri- 
buted, cannot  it  be  easily  conceived  that  it  may  be  possible  that 
a  hepatized  lung,  or  bronchiae  that  have  suppurated,  will  for  a 
long  time,  if  not  always,  preserve  the  traces  of  the  pathological 
modifications  supervening  in  their  tissue,  and  thereby  become 
less  suitable  to  fulfil  their  functions  ?  It  is  perhaps  to  pneumo- 
nia developed  during  intra-uterine  life,  or  after  birth,  that  short 
breathing,  husky  voices,  asthmas,  or  idiopathic  coughs,  with 
which  some  individuals  are  aifected,  are  to  be  attributed.  This 
supposition  will  appear  less  strange,  if  the  numerous  lesions  to 
which  our  organs  are  exposed  from  the  first  moment  of  their 
formation  are  considered. 

Art.  3. — Bronchitis,  or  Bronchial  Catarrh. 

Inflammation  of  the  bronchiae  may  exist  in  new-born  infants 
without  producing  any  well-marked  symptoms.  I  have,  in  four 
instances,  seen  the  remote  ramifications  of  the  bronchia3  very 
red  and  filled  with  thick  mucosities,  in  the  body  of  a  child  who 
had  died  eight  or  ton  days  after  birth,  and  where  there  had  nei- 
ther been  any  rale  nor  cough  during  life.  In  two  of  these  children 
there  was  pneumonia  with  pulmonary  engorgement ;  in  two 
others  the  lungs  were  healthy,  and  death  occurred  from  intesti- . 
nal  phlegmasia.  But  bronchitis  is  not  always  so  obscure ;  for 
the  most  part  it  is  easily  recognised,  and  the  diagnosis  of  the 
symptoms  is  much  more  easily  made  as  the  child  advances  in 
age.  The  following  is  an  instance  of  an  infant  of  fifteen  days, 
with  symptoms  of  acute  bronchitis,  with  its  peculiar  characters 
strongly  marked. 

CASE  LXXIII. — Acute  Bronchitis. — Michel  Colot,  aged  fifteen 
days,  of  a  strong  constitution,  not  having  been  sick  from  the  time  of 
birth,  was,  on  the  22d  of  November,  taken  with  a  violent  cough,  ac- 
companied with  a  rale  which  could  be  heard  without  recourse  to 
auscultation.  Respiration  was  frequent,  the  chest  was  sonorous 
throughout;  the  skin  was  burning;  the  pulse  small  and  frequent; 
an  erythema  appeared  on  the  posterior  part  of  the  thighs.  (Gummed 
decoction  of  marshmallows,  pectoral  electuary,  milk  and  water.) 
On  the  twenty-sixth,  same  condition  ;  face  pale  and  (Edematous  ;  the 
child  slept  but  little  and  cried  much.     There  was  an  incessant  cough 


ON    THE    DISEASES    OF    INFANTS.  417 

accompanied  with  danger  of  suffocation,  which  continued  for  some 
minutes.  On  the  twenty-eighth,  respiration  could  be  heard  better  on 
the  right  than  on  the  left  side,  where  percussion  produced  a  slightly- 
dull  sound.  The  same  treatment  was  continued.  On  the  twenty^ 
ninth,  the  integuments  of  the  face  and  trunk  became  livid  ;  the  mu- 
cous rale  was  very  distinct ;  the  cough  was  very  frequent^  and  ac- 
companied with  imminent  danger  of  suffocation  ;  the  child  became 
very  restless  ;  a  copious  diarrhoea  occurred  ;  the  abdomen  was  soft ; 
the  skin  burning  hot ;  the  pulse  small  but  of  extreme  quickness  ; 
finally,  death  occurred  on  the  night  of  the  twenty-ninth. 

On  a  post  mortem  examination  the  mouth  and  oesophagus  were 
found  pale  ;  the  stomach  contracted,  wrinkled,  and  streaked  with 
red  ;  the  left  lung  infiltrated  with  blood  ;  all  the  bronchial  ramifica- 
tions were  very  red  and  tumefied,  and  were  found  filled  with  thick, 
reddish,  filamentous  mucosity  ;  the  right  lung  was  likewise  engorg- 
ed ;  the  bronchiae,  like  those  of  the  left  lung,  were  red,  and  filled 
with  thick,  yellow,  ropy  mucosity  ;  the  heart  was  healthy  ;  the  foetal 
openings  still  free  ;  the  brain  firm ;  all  the  tissues  were  in  general 
gorged  with  fluid  and  dark-colored  blood. 

When  bronchitis  supervenes  on  pneumonia,  the  smaller  divi- 
sions of  the  bronchiae  are  the  parts  that  are  inflamed.  It  even 
happens  that  the  first  ramifications  near  the  trachea  do  not  par- 
ticipate in  the  inflammation.  Wherever  the  seat  of  the  inflam- 
mation is,  it  is  sometimes  accompanied  with  very  serious  symp-- 
toms,  which  arise  from  the  difficulty  with  which  the  air  pene- 
trates the  lungs.  I  have  seen,  in  several  children,  bronchial 
catarrh  give  rise  to  all  the  symptoms  which  authors  have  re- 
ferred to  suffocating  catarrh,  and  which  M.  Gardien  observes  is 
the  result  of  an  infiltration  of  serosity  in  the  pulmonary  tissue.* 
The  suffocation  with  which  the  child  is  threatened  appears  to  me 
to  be  the  effect  of  several  modifications  of  the  phlegmasia  of  the 
air  passages ;  its  cause  is  not  always  the  same ;  it  is  sufficient  for 
its  occurrence  that  the  phlegmasia  has  produced  some  obstacle  to 
the  passage  of  the  air*  We  have  already  seen  this  morbid  phe- 
nomenon arise  in  several  instances,  and  it  can,  without  doubt,  be 
pointed  out  on  several  other  occasions. 

Brohphial  catarrh  may  pass  to  a  chronic  state,  and  cause,  for  a 
long  tini^,  a  secretion  of  mucosities  from  the  trachea  and  bron- 

V 

*,Gardien,  Traite  des  Maladies  des  Enfans^  t.  4,  p.  302. 
53 


418  ON    THE    DISEASES    OF    INFANTS. 

chias.  It  is  often,  in  children,  symptomatic  of  phlegmasia  of  the 
puhnonary  tissue.  Sometimes,  indeed,  it  is  accompanied  with 
tubercles  situated  in  the  lungs  or  root  of  the  bronchiae  ;  in  every 
instance  it  gives  rise  to  a  series  of  peculiar  symptoms,  and 
which  enable  us  to  recognise  it.  Such,  for  instance,  in  infants 
that  have  attained  the  age  of  ten  months  or  a  year,  as  constant 
cough,  oppression,  quick  noisy  respiration,  very  evident  mu- 
cous rale,  fever,  continual  heat  of  the  skin,  paleness  and  tume- 
faction of  the  face.  To  these  symptoms  there  is  often  added  an 
inflammation,  more  or  less  intense,  of  the  digestive  tube,  the  mu- 
cous membrane  of  which  is  disorganized,  without  color,  and  is 
even  sometimes  softened.  I  have  found  the  mucous  membrane 
of  the  trachea  and  bronchiae,  in  several  infants  that  have  died  of 
chronic  catarrh,  covered  with  red  streaks,  whilst  the  bronchial 
ramifications  presented  a  uniform  and  intense  redness,  and  were 
at  the  same  time  filled  with  thick  and  adherent  mucosity. 

Acute  bronchial  catarrh  in  new-born  children  may  be  of  very 
short  duration ;  it  sometimes  arises  without  .any  appreciable 
cause,  and  disappears  spontaneously  at  the  end  of  a  few  days. 
There  is  very  often  no  other  symptom  than  the  mucous  rale,  or 
short,  noisy,  and  frequent  respiration,  without  any  well  charac- 
terized rale.  In  older  children  it  is  in  general  more  obstinate, 
and  always  produces  cough  ;  some  children  will  even  retain  it 
for  a  very  long  time,  and  will  pass  through  the  period  of  suckling 
without  being  freed  from  it.  and  without  experiencing  any  serious 
injury  to  their  health  j  in  general,  chronic  bronchitis  need  not 
be  regarded  as  a  serious  affection  when  they  do  not  become  ema- 
ciated, when  they  preserve  the  appetite,  and  the  usual  gaiety  and 
vivacity  of  their  age.  The  usual  termination  of  bronchial 
phlegmasia  is  resolution  ;  I  have  found  but  once,  on  examining 
the  dead  body  of  a  child,  that  I  had  not  seen  during  its  life,  a 
well-marked  cedema  of  the  bronchiae  ;  in  another  an  abundant 
sanguineous  exhalation  :  the  ages  of  both  were  but  five  days. 

The  treatment  pointed  out  for  pneumonia  will  also  be  applica- 
ble to  bronchitis,  which  is  frequently  accompanied  by  inflamma- 
tion of  the  lungs.  Yet  it  would  perhaps  be  necessary  in  this 
case  to  niake  use  of  blisters  more  freely  between  the  shoulders, 
or  on  the  arms,  particularly  when  the  disease  becomes  chronic. 
When  this  is  the  case,  we  might  also  resort  to  the  balsam  of  co- 


ON   THE    DISEASES    OF    INFANTS.  419 

paiba,  in  doses  of  a  few  grains  each  day,  increasing  the  dose  ac- 
cording to  the  age  of  tlie  child.  Dr.  La  Roche,  a  physician  of 
Philadelphia,  has  met  with  great  success  in  the.  use  of  this  medi- 
cine. He  has  published  an  essay  on  the  subject,  which,  while  it  con- 
tains a  number  of  interesting  facts,  still  leaves  it  evident  that  fur- 
ther experience  is  needed  to  confirm  the  efficacy  of  this  medicine.* 
Mr.  Thorn  has  made  a  resinous  extract  of  copaiba;  which  is  de- 
prived of  its  essential  oil,  where  the  unpleasant  taste  and  smell  of 
this  medicine  reside,  without  removing  its  properties.  Mr.  Tyr- 
rell has  used  this  extract  with  great  success  in  gonorrhoea  in  St. 
Thomas'  hospital.  It  would  probably  be  well  to  use  it  in  the 
place  of  the  balsam  af  copaiba  when  it  is  desired  to  administer 
it  to  children  affected  with  chronic  bronchitis,  when  the  ordinary 
means  have  not  succeeded  in  curing  the  disease. 

Art.  4. — Pleurisy. 

Pleurisy  is  more  common  among  young-  infants  than  is  gene- 
rally believed ;  it  often  appears  without  the  lungs  participating 
in  the  inflammation.  I  have  seen  several  infants  die  immediately 
after  birth  from  this  affection. 

CASE  LXXIV.— JLcwfe  pleurisy. — Averan,  aged  two  days,  was 
exposed  at  the  Hospice  des  Enfans  Trouves,  on  the  14th  of  Novem- 
ber. He  was  strong,  and  the  integuments  highly  colored  ;  the  cry 
full  and  complete  ;  he  was  constantly  restless,  and  cried  without 
ceasing ;  the  face  became  purple  and  pinched  ;  the  child  obtained  no 
sleep  at  night,  and  appeared  to  suffer  more  when  placed  in  the  bed. 
On  the  morning  of  the  fifteenth,  the  same  state  continued  ;  the  chest,, 
when  percussed,  gave  a  dull  sound  in  every  part;  at  night  the  child 
became  exhausted  from  fatigue,  appeared  to  faint,  and  died.  On 
opening  the  body  the  following  day,  the  digestive  tube  was  found 
healthy ;  the  two  cavities  of  the  thorax  contained  a  quantity  of  yel- 
low serosity,  in  the  middle  of  which  were  a  number  of  albuminous 
flakes  ;  there  were  no  adhesions'between  the  pleura  ;  the  two  lungs 
floated  on  water,  the  left  only  was  slightly  engorged  at  its  posterior 
border;  the  foetal  openings  were  free;  the  meninges  of  the  brain 
were  healthy 

*  La  Pwoche,  On  copaiba  balsam  in  chronic  bronchitis.  (North  American  Medical 
and  Surgical  Journal,  No.  VI,  p.  34.) 


420  ON   THE    DISEASES   OF    INFANTS. 

The  great  restlessness  of  this  child  was,  without  doubt,  owing 
to  the  development  of  pleurisy,  and  the  pain,  which  the  lying  on 
the  back  made  so  much  more  distressing,  proceeded  from  the  ef- 
fusion of  serosity  in  the  pectoral  cavity.  The  signs  of  pleurisy 
were  not  well  marked,  and  I  have  only  given  this  example  to 
show  that  restlessness,  cries,  sleeplessness,  and  death  of  new-born 
children  may  sometimes  be  owing  to  acute  pleurisy.  We  will, 
however,  observe  that  one  of  the  signs  of  this  disease  is  a  dull 
sound  of  the  chest,  although  the  cry  may  not  be  altered.  This 
would  lead  to  the  belief  that  if  the  disease  exists  in  the  thorax, 
the  lungs  are  probably  not  its  seat,  since  the  air  penetrates  suifi- 
ciently  in  their  tissue  to  preserve  the  cry  in  its  normal  state. 

We  shall  see,  in  the  following  instance,  pleurisy  appearing  in 
a  manner  more  evident  than  in  the  foregoing  case  : 

CASE  LXXV. — Pleurisy. — Victoire  Redan,  aged  ten  days, 
strong  and  of  a  good  color,  and  presenting  all  the  appearances  of 
health,  entered  the  infirmary  on  the  night  of  the  30th  of  October. 
This  child  had  been  vaccinated  on  the  second  day  after  birth ;  the 
pustule  was  not  well  developed,  and  there  existed  no  inflammatory 
circle  around  it.  She  was  attacked  with  an  abundant  diarrhoea  of  a 
yellow  color.  The  face,  which,  until  the  time  of  admission,  had 
been  of  a  vermilion,  was  pale  and  wrinkled,  particularly  at  the 
external  angles  of  the  eyes,  and  on  the  forehead  ;  she  cried  but  little, 
but  the  cry  was  plaintive.  The  pulse  was  very  small,  but  exhibited 
nothing  remarkable  with  regard  to  its  frequency.  On  the  1st  of 
November  there  was  the  same  expression  of  face,  the  extremities 
were  cold,  trunk  intensely  hot ;  a  marked  dulness  on  percussion  on 
the  right  side  of  the  chest ;  the  cry  was  expressive  of  fatigue,  but 
without  being  husky ;  when  the  child  was  unclothed  and  examined, 
during  respiration,  the  thorax  was  observed  to  dilate  with  diflliculty, 
and  that  the  movements  of  the  diaphragm  and  parietes  of  the  abdo- 
men were  very  evident.  [Gummed  electuary.)  On  the  4th  of  No- 
vember, there  was  an  abundant  vomiting,  cry  painful,  hmbs  cold, 
face  pale,  and  the  alae  of  the  nose,  which  appeared  to  dilate  with 
difficulty,  were  livid  ;  the  mouth  remained  open,  or  opened  and 
closed  alternately  during  the  movements  of  respiration.  Respira- 
tion could  not  be  heard  through  the  stethoscope  at  any  point  of  the 
thorax,  yet  the  dulness  was  not  very  evident  on  percussion,  espe- 
cially at  the  upper  part  of  the  thorax.     {Two  leeches  to  the  lateral 


ON   THE    DISEASES    OF    INFANTS.  421 

parts  of  the  thorax,  linctus.)  On  the  fifth,  general  sinking,  ex- 
treme paleness,  and  death  at  night. 

On  examining  the  body,  there  was  found  a  passive  congestion  at 
the  base  of  the  tongue  and  oesophagus,  where  were  also  found  some 
spots  of  muguet,  and  softening  of  the  mucous  membrane  of  the 
small  intestines. 

The  lungs  were  slightly  red,  and  injected  with  a  considerable 
quantity  of  frothy  serosity,  which  flowed  from  every  part  when  cut. 
The  right  lung  exhibited  the  first  stage  of  hepatization  at  its  poste- 
rior border;  a  very  fine  spotted  redness  existed  on  the  pleura  of 
both  sides ;  there  was  about  two  spoonfuls  of  serosity  effused  in 
each  thoracic  cavity,  and  the  base  of  the  lungs  adhered  to  the  dia- 
phragm by  tender  albuminous  filaments  of  a  very  slight  consistence, 
of  a  citron  color,  like  the  effused  fluid.  The  brain  was  healthy,  but 
the  venrticles  were  filled  with  serosity. 
m 

We  must  again  remark  the  restlessness  and  painful  expression 

of  the  physiognomy  of  the  child,  the  difficulty  of  respiration,  the 
constantly  increasing  dulness  of  the  thorax,  although  the  cry 
did  not  become  altered  in  proportion  as  the  disease  advanced  ; 
the  coldness  and  lividness  of  the  extremities,  while  the  body  Avas 
at  a  very  high  temperature.  I  will  not  speak  of  the  pulse,  which, 
in  this  disease,  as  in  almost  all  others  of  new-born  children,  is  very 
uncertain,  and  of  little  use  in  diagnosis.  Notwithstanding  all  the 
care  I  have  taken  to  ascertain  correctly  the  symptoms,  I  am  not 
able  to  offer  any  thing  of  sufficient  precision  to  enable  us  to  make 
a  correct  diagnosis  of  pleurisy  ;  but  the  symptoms  mentioned  are 
at  least  enough  to  satisfy  us  that  there  exists  a  great  probability 
of  the  presence  of  the  disease  now  under  consideration,  and  this 
is  all  we  can  obtain  at  the  bedside,  when  we  wish  to  ascertain 
the  seat  and  nature  of  the  diseases. 

Chronic  'pleurisy. — Pleurisy  may  pass  into  a  chronic  state 
even  in  very  young  children,  and  give  rise  to  changes  in  the 
tissue  similar  to  those  observed  in  adults.  A  little  girl,  aged 
three  months,  who  had  been  feeble,  pale,  and  sickly  from  birth, 
and  who  had  been  several  times  in  the  infirmary  with  the  most 
uncertain  symptoms,  died  at  last  on  the  18th  of  April,  1826.  She 
had  insensibly  arrived  at  the  last  stage  of  marasmus,  and  had  not 
been  affected  with  diarrhoea  except  in  the  latter  period  of  life ; 
she  had  never  been  affected  with  fever,  and  although  the  respira. 


422  ON   THE    DISEASES    OF    INFANTS. 

tjon  was  short,  the  tone  of  the  cry  did  not  exhibit  any  aheration, 
and  the  nurse  remarked  that  the  child  died  from  languor.  Upon 
opening  the  body,  I  found  the  small  intestines  red,  tumefied,  and 
filled  with  a  large  quantity  of  black  blood  in  clots ;  the  large  in- 
testines were  healthy.  There  also  existed  a  very  violent  pleu- 
risy on  the  left  side.  Both  the  costal  and  pulmonary  pleurae 
were  covered  with  a  layer  of  plastic  lymph,  at  least  a  line  and  a 
half  in  thickness.  When  this  lymph  was  removed,  the  pleura 
beneath  was  found  rugous  and  very  much  injected,  while  the 
lungs  under  its  coating  were  found  crepitant  and  perfectly 
healthy.  When  the  lungs  were  cut  transversely,  a  well-marked 
red  line  could  be  seen  at  the  circumference  of  this  organ,  indi- 
cating the  separation  between  the  inflamed  pleura  and  the 
healthy  pulmonary  tissue.  The  heart  and  large  vessels  were 
exsanguined ;  the  foetal  openings  obliterated ;  the  brain,  although 
healthy,  contained  a  small  quantity  of  serum  in  the  ventricles. 

From  what  has  been  related,  we  have  seen  that  the  emacia- 
tion and  languor  of  this  child  were  caused  by  an  obscure  pleurisy, 
the  progress  of  which  insensibly  led  to  the  death  of  the  patient. 
In  every  instance,  therefore,  in  which  we  see  a  child  languish- 
ing, and  becoming  thin  and  feeble,  we  ought  carefully  to  search 
for  the  cause  of  this  condition,  and  endeavor  to  ascertain  whether 
it  does  not  arise  from  some  obscure  organic  lesion  ;  we  ought  not 
to  remain  in  a  security  which  would  leave  us  tranquil  spectators 
of  a  disease  Avhich  perhaps  might  not  have  terminated  fatally  if 
we  had  examined  with  scrupulous  attention  into  its  cause,  seat, 
and  nature. 

As  a  general  rule,  it  is  not  easy  to  make  a  diagnosis  of  pleurisy 
in  young  infants  ;  still  its  existence  may  be  suspected  when  we 
observe  much  anxiety,  restlessness,  difficulty  of  breathing,  pain- 
ful dilatation  of  the  thorax,  quick  and  more  marked  contractions 
of  the  diaphragm  and  abdominal  muscles  ;  and  in  the  midst  of . 
these  symptoms,  if  the  cry  should  preserve  its  integrity,  and 
present  no  other  alteration  than  that  which  arises  from  fatigue 
and  exhaustion.  Percussion  and  auscultation  give  but  very  un- 
certain signs  in  this  disease  ;  yet  if  the  respiration  be  not  heard 
at  any  part  of  the  thorax  while  the  cry  is  complete  and  free,  and 
when  there  would  appear  as  if  there  existed  effusion  without  he- 
patization, the  infant,  in  all  probability,  is  affected  with  pleurisy; 


ON   THE    DISEASES    OF    INFANTS.  423 

this  conclusion  will,  however,  be  still  uncertain.  I  must,  on  this 
account,  consider  the  diagnosis  of  pleurisy  in  sucking  children  as 
very  difficult,  and  that  it  is  very  easy  to  confound  it  with  pneu- 
monia. Happily  this  mistake  cannot  be  very  prejudicial  to  the  pa- 
tient, because  the  treatment  of  the  one  will  be  the  best  that  can 
be  adopted  for  the  other. 

The  treatment  of  pleurisy  will  differ  very  little  from  that  of 
pneumonia  ;  four,  six,  or  eight  leeches  ought  to  be  applied  to  the 
thorax,  and  the  whole  of  the  chest  covered  with  a  cataplasm, 
while  a  revulsion  is  made  to  the  arms  or  legs  by  means  of  flying 
blisters  or  sinapisms.  After  sanguineous  depletion,  dry  cups  or 
blisters  may  be  used  to  the  thorax  ;  and  if  the  disease  become 
chronic,  it  would  be  useful  to  clothe  the  infant,  however  young 
it  may  be,  with  a  flannel  waistcoat  applied  directly  to  the  skin. 

Oedema  of  the  lungs. — This  disease  consists  of  a  serous  in- 
filtration more  or  less  abundant  in  the  pulmonary  tissue ;  it  is 
rarely  a  primary  affection,  but  is  more  often  a  sequel  of  chronic 
pneumonia  or  pleurisy ;  it  sometimes  is  a  fatal  termination  of 
these  diseases.  I  have  several  times  found  the  lungs  oedematous 
in  the  case  of  oedema  or  induration  of  the  cellular  tissue  ;  they 
are  in  a  state  analogous  to  that  of  all  other  parts  of  the  body. 

Whatever  be  the  cause  of  oedema  of  the  lungs,  it  gives  rise  to 
the  most  serious  symptoms,  and  especially  to  a  very  laborious 
respiration  ;  yet  I  have  found  very  often  a  considerable  quantity 
of  serosity  in  the  lungs  of  infants  who  have  not  exhibited  any 
particular  symptom  of  disorder  in  the  chest ;  it  is  very  probable 
that  this  oedema  occurs  at  the  moment  of  dissolution,  and  must 
be  regarded  perhaps  as  a  phenomenon  of  death.  However,  it 
would  appear  as  if  this  disease  may  occur  without  being  caused 
by  any  antecedent  lesion,  and  give  rise  to  a  series  of  symptoms 
which  have  been  described  with  great  care  by  M.  Gardien, 
among  which  he  mentions,  particularly,  cough,  extreme  difficulty 
of  respiration,  and  the  imminent  danger  from  suffocation.  When 
the  children  that  I  have  observed  exhibited  symptoms  analogous 
to  those  pointed  out  by  M.  Gardien  as  the  effect  of  oedema,  I  have 
several  times  found  the  lungs  infiltrated  with  serosity,  but  there 
was,  at  the  same  time,  pneumonia,  pleurisy,  or  bronchitis,  so  that 
I  could  not  attribute  these  symptoms  solely  to  the  presence  of  se- 
rosity. 


424  ON  thu  diseases  of  infants. 

However  this  may  be,  I  think  that  if  it  were  possible  to  distin- 
guish oedema  of  the  lungs  from  pneumonia  or  pleurisy  in  young 
infants,  the  application  of  a  blister  to  the  limbs  or  thorax  would 
answer  a  better  end  than  sanguineous  evacuations.  Purgatives, 
and  the  oxymel  of  squills,  appear  to  me  to  be  also  indicated. 

Art.  5.—  Hooping-cough. 

I  will  here  record,  as  concisely  as  possible,  the  result  of  the 
researches  made  of  the  opinions  published  respecting  hooping- 
cough  since  its  first  appearance  in  Europe.  I  will  endeavor  to 
estimate  these  opinions  according  to  their  just  value,  and  to  as- 
certain what  is  positive,  and  draw  such  practical  inferences  as 
will  naturally  arise  in  the  description  of  the  subject. 

This  disease  is  characterized  by  a  suffocating  cough,  returning 
in  paroxysms,  accompanied  by  an  excretion  of  a  very  abundant 
mucus,  and  always  accompanied  with  a  vomiting  of  mucus, 
caused  doubtless  by  the  irritation  of  the  stomach,  the  internal 
membrane  of  which  appears  to  participate  in  the  catarrhal  dis- 
ease of  the  bronchise.  During  a  fit  of  coughing,  the  child  ex- 
periences all  the  symptoms  naturally  arising  from  immediate  suf- 
focation— such  as  congestion  of  the  face,  injection  of  the  con- 
junctiva, shedding  of  tears,  and  a  general  spasmodic  condition 
excited  by  the  difficulty  of  respiration.  The  cough  has  some- 
thing hoarse  and  resounding  peculiar  to  it.  I  shall  not  stop  to 
consider  the  appropriateness  of  the  terms  by  which  the  French, 
Germans,  and  English  designate  this  disease.  They  are  all  in- 
dications of  the  symptoms,  rather  than  the  nature  of  the  disease.* 

The  causes  of  this  catarrhal  inflammation,  like  those  of  all 
other  epidemics,  are  difficult  to  ascertain.  The  only  positive 
thing  that  can  be  said  about  it  is,  that  it  is  not  really  contagious, 
but  an  epidemic  disease,  a  distinction  which  M.  Gardien  has  in- 
sisted on  with  great  reason.  It  prevails  often  at  the  same  time 
with  ordinary  catarrh,  sometimes  taking  its  place,  or  complica- 
ting and  modifying  it,  and  imparting  to  it  some  of  its  peculiar 
characters.    It  has  sometimes  occurred  before  an  epidemic  of 

*  The  word  coquduchcis,  it  is  said,  derived  from  an  old  custom  of  covering  the  head 
of  the  patient  with  a  hood  or  capuchon.  The  German  words  keichhusten  and  stick- 
kusten^  and  EngUsh  expression  hooping-cough,  signify  a  convulsive  cough. 


ON    THE    DISEASES    OP   INFANTS.  425 

croup,  or  the  latter  disease,  may  be  developed  in  the  middle  of. 
hooping-cough  prevailing  epidemically ;  so  that  the  usual  causes 
giving  rise  to  simple  catarrh,  croup,  or  hooping-cough,  appear  to 
be  connected  by  relations  and  analogies,  the  characters  of  which 
escape  us,  it  is  true,  but  which  allow  us  to  see  their  simultaneous 
or  consecutive  effects.  During  the  time  J  was  at  the  Hospice 
des  Enfans  Trouves,  I  saw  at  the  house  of  a  nurse  who  lived 
near  the  "  barriere  d'Enfer,"  three  children,  aged  from  ten  to 
eighteen  months,  who  were  affected  in  the  space  of  three  months 
with  measles,  accompanied  by  a  slight  anginose  affection,  simple 
bronchial  catarrh,  which  soon  assumed  the  characters  of  hooping- 
cough,  and  lastly  with  croup  ;  all  these  occurred  successively  in 
three  children,  and  cut  them  off  in  eight  days. 

It  is  difficult  for  us  positively  to  ascertain  the  nature  of  hoop- 
ing-cough, but  we  may  still  obtain  some  knowledge  of  its  prin- 
cipal characters.  Thus  it  is  evident  that  it  is  a  bronchial  ca- 
tarrh, which  can  be  discovered  by  the  most  superficial  examina- 
tion of  the  symptoms  of  the  patient.  This  catarrh,  however,  has 
something  peculiar  ;  the  cough  which  it  produces  is  always  suf- 
focating, convulsive,  and  only  occurs  in  paroxysms.  This  ner- 
vous complication  is  to  be  noted,  for  here  its  specific  character 
commences,  and  we  can  see  it,  but  are  unable  to  explain  it  with- 
out hazarding  the  danger  of  wandering  into- futile  hypotheses; 
yet  I  will  make  one  remark  in  relation  to  this  nervous  complica- 
tion ;  it  is,  that  in  adults,  as  well  as  in  children,  affections  of  the 
trachea,  larynx,  and  also  of  the  bronchia,  often  give  rise  to  a  sud- 
den local  or  general  spasmodic  irritation,  characterized  by  spasm 
of  the  affected  organ,  or  by  general  convulsions.  Tonsilitis,  sim- 
ple angina,  croup,  foreign  bodies  in  the  trachea,  or  tumors  com- 
pressing the  trachea  or  bronchise,  produce  a  cough  more  or  less 
suffocating,  very  remarkable  for  its  remissions,  and  which,  in 
some  cases,  has  a  striking  resemblance  to  that  of  hooping-cough. 
Admitting,  therefore,  the  specific  nature  of  catarrh  in  this  dis- 
ease, and  that  it  consists  especially  in  a  nervous  complication, 
we  are  disposed  to  the  opinion  that,  in  many  other  instances, 
the  diseases  of  the  same  organ  may  exhibit  very  evidently  a  ner- 
vous complication ;  whence  it  will  follow,  that  if  in  a  similar 
complication  consists  the  specific  nature  of  hooping-cough,  the 

seat  of  the  disease  and  the  physiological  lesion  which  exists  be- 

54 


426  ON   THE    DISEASES    OF    INFANTS. 

tween  it  and  the  nervous  system,  may  concur  in  a  manner  that 
will  produce  the  specific  quality  of  the  disease  in  question.  The 
same  disease,  in  different  parts  of  the  system,  often  presents  va- 
rious characters ;  different  diseases  having  the  same  seat,  some- 
times exhibit  analogous  characters ;  the  seat  of  the  affection  then 
has  something  that  imparts  a  specific  quality  to  diseases  in  gene- 
ral, and  ought  to  be  considered  when  treating  them. 

There  is  also  another  circumstance  which  ought  to  be  consi- 
dered as  peculiar  to  hooping-cough — that  is,  the  coexistence  of 
mucous  vomitings,  effected  by  the  cough.  This  coexistence  is 
easily  explained  by  the  relation  existing  between  the  mucous 
membrane  of  the  bronchiae  and  that  of  the  stomach,  and  the  fre- 
quency of  the  cough  very  naturally  accounts  for  the  frequency 
of  vomiting. 

I  do  not  pretend  that  I  have,  by  the  preceding  explanation, 
satisfactorily  accounted  for  the  specific  nature  of  hooping-cough, 
but  have  only  endeavored  to  exhibit  one  of  the  possible  causes 
of  it ;  and  there  remains  sufficient  to  call  forth  all  our  efforts  to 
unveil  the  nature  of  this  disease.  Some  of  the  most  enlightened 
observers  have  exercised  their  talents  in  the  investigation  of  this 
subject ;  such  as  Rosen,  CuUen,  Schoefer,  Hufeland,  Matha'i, 
John,  Authenrieth,  Baumes.  All  have  discovered,  on  examining 
the  bodies  of  those  who  have  died  of  this  disease,  the  existence 
of  bronchial  catarrh,  without  any  particular  lesion  of  the  bron- 
chiae. This  opinion  is  sustained  particularly  by  Dr.  Watt,  of 
Glasgow,*  Albers  of  Bremen,  Marcus,t  Desruelles,t  and  Ad. 
Hencke,  who  in  his  learned  work  appears  to  adopt  the  same 
opinion. § 

Hufeland  thinks  that  the  eighth  pair  of  nerves  may  have  some 
agency  in  the  production  of  this  disease,  and  is  probably  the 
cause  of  the  double  irritation  of  the  bronchiae  and  stomach  which 
sometimes  appears.  II    This  opinion,  revised  by  M.  Breschet,  who 

*  Treatise  on  the  nature  and  treatment  of  chin  cough,  including  a  variety  of 
cases  and  dissections,  by  Robert  Watt,  M.  D.,  Glasgow,  1815. 

t  Traite  de  la  coqueluche,  ou  bronchite  epidemique,  son  diagnostic,  sa  nature,  et 
son  traitment,  translated  from  the  German  by  E.  L.  Jacques.     Paris,  1821. 

t  Traite  de  la  coqueluche.     Prize  essay.     Paris,  1827. 

§  Handbuch.  der  Kindcrkrankeiten.     Frankfort,  1821. 

II  Si/stcm  der  praktische  hielkunde.     Jena,  1818 — 1828. 


ON   THE    DISEASES    OF    INFANTS.  427 

found  in  two  individuals  that  died  of  catarrh  accompanied  with 
a  suffocating  cough,  the  pneumo-gastric  nerves  red  externally 
and  yellow  internally,  has  not  been  confirmed  by  the  indefatiga- 
ble researches  of  M.  Guersent ;  and  I  have,  in  every  instance  of 
death  from  hooping-cough,  dissected  the  pneumo-gastric  nerve, 
without  ever  being  able  to  discover  any  lesion ;  so  that  this  idea 
must  be  considered  as  not  yet  demonstrated. 

Lastly,  Authenrieth,  from  the  success  which  followed  his  me- 
thod of  treatment,  is  of  opinion  that  hooping-cough  is  owing  to 
an  accumulation  of  lymph  towards  the  bronchiae,  and  that  this 
cause  can  be  removed  by  causing  exteriorly  the  formation  of 
pustules  which  contain  lymph.* 

The  examination  of  bodies  has  not  exhibited  any  thing  uni- 
form in  this  disease,  except  bronchial  catarrh  in  various  stages 
of  advancement,  almost  always  accompanied  with  a  considerable 
quantity  of  mucosity  accumulated  in  the  bronchia3,  which  are 
sometimes  sensibly  dilated,  and  exhibit  a  vivid  red  color.  Among 
the  concomitant  lesions  of  the  catarrh,  there  are  very  often  found 
inflammation  of  the  lymphatic  ganglia  in  the  vicinity  of  the  bron- 
chiae, and  a  dilatation  of  the  termination  of  the  bronchiae,  pointed 
out  for  the  first  time  by  Laennec.  I  once  saw  this  in  a  child  of 
fifteen  months,  and  who  presented  at  the  extremities  of  the  bron- 
chiae a  species  of  small  vesicles  filled  with  a  creamy,  inodorous  pus. 
The  unequal  dilatation  of  the  bronchiae  has  also  been  met  with 
in  some  infants  ;  it  is  the  same  in  emphysema ;  lastly,  this  dis- 
ease is  found  complicated  with  pneumonia,  pleurisy,  pulmonary 
tubercles,  chronic  enteritis,  mesenteritis,  menengitis,  hydrocepha- 
lus ;  but  in  considering  the  variety  and  number  of  these  compli- 
cations, do  we  not  see  also  that  some  are  the  ordinary  result  of 
pulmonary  affections  of  long  duration,  and  other  accidental 
effects  of  peculiar  idiosyncracy  ?  Wherefore,  then,  seek  among 
all  the  complications  of  hooping-cough  for  lesions,  which  will 
give  us  a  proper  idea  of  the  seat  and  nature  of  the  disease,  whilst 
there  exists  one  princpial  lesion  always  constant,  always  identi- 
cal, to  which  it  is  more  natural  to  refer  the  prerogative  of  being 
one  of  the  principal  causes  of  hooping-cough  ?  I  am  sensible 
how  much  the  nature  of  the  discussion  upon  which  we  have 

*  Versuchejiur  diepraktische  heil!:u7idc.     Tubingue,  1808. 


428  ON   THE    DISEASES    OF    INFANTS. 

entered  is  calculated  to  lead  us  into  vain  speculations ;  I  will 
hasten  then  to  trace  the  progress  of  the  symptoms  and  the  treat- 
ment of  this  disease. 

All  authors  since  the  time  of  Rosen  have  recognised  different 
periods  in  the  disease,  and  M.  Guersent,  in  his  excellent  article 
Coqiieluchej  in  the  Dictionnaire  de  medicine,  has  traced  them 
with  great  care.  The  development  of  this  disease  doubtless  ex- 
hibits several  stages,  but  notwithstanding  the  attention  I  have 
bestowed  on  the  subject,  I  have  found  them  so  variable  with  re- 
spect to  their  duration,  and  even  their  characters,  that  I  believe 
it  to  be  impossible  to  assign  to  them  any  constant  symptoms  or 
limits. 

Hooping-cough  always  commences  with  simple  bronchial 
catarrh ;  and  even  during  its  prevalence  as  an  epidemic,  many 
children  have  nothing  more  than  a  catarrh,  which  terminates  at 
the  end  of  a  few  days  or  weeks  without  ever  exhibiting  the  cha- 
racters of  hooping-cough,  whilst  other  children  living  under  the 
same  atmospheric  influence  have  the  disease  wifh  all  its  pecu- 
liar traits.  Is  it  that  some  have  a  false  and  others  a  true  hoop- 
ing-cough ?  It  would  be  scarcely  in  place  to  repeat  what  has 
been  said  of  croup  with  regard  to  this  question.  It  is  much 
more  reasonable  to  believe  that  the  disease  has  existed  in  these 
children  in  different  degrees,  and  that  it  varies  in  them  from  a 
slight  to  a  severe  affection.  When  the  cough  increases,  with 
the  irritation  of  the  bronchias,  the  face  becomes  puffed,  the  eyes 
injected,  the  respiration  accelerated ;  the  expectoration  is  at  first 
thin,  limpid,  and  serous  ;  the  cry  and  voice  become  peculiar  in 
their  tone,  easily  recognised  by  experienced  practitioners.  1 
have  often  seen  children  with  the  disease  confined  to  simple 
bronchial  catarrh,  and  continue  for  a  long  time  only  affected 
with  it  in  this  simple  form.  I  remember  particularly  a  little  girl 
at  the  infirmary  of  the  Hospice  des  Enfans  Trouves,  who  had  a 
peculiar  cough,  accompanied  with  symptoms  of  suffocation  and 
an  abundant  expectoration,  which  lasted  about  forty-eight  hours. 
It  was  thought  that  the  hooping-cough  was  about  to  be  devel- 
oped, to  continue  for  a  greater  or  less  time  ;  nothing  of  this  kind, 
however,  occurred,  and  the  symptoms  disappeared  rapidly  with- 
out any  active  treatment;   and  although  this  child  remained 


.ON   THE    DISEASES    OF    INFANTS.  429 

some  time  in  the  infirmary,  there  existed  no  more  symptoms  of 
suffocating  catarrh. 

When  hooping-cough  becomes  severe,  the  chest,  particularly 
about  the  sternum,  is  the  seat  of  considerable  pain  ;  the  cough 
returns  in  paroxysms,  with  shorter  intervals  between  them,  in- 
creasing more  at  night,  and  is  almost  always  preceded  by  a  mu- 
cous rale,  which  is  more  evident  as  the  paroxysms  approach  each 
other.  In  a  fit  of  coughing,  the  suffocation,  pain,  and  strangling 
produce  the  greatest  distress  in  the  patient,  who  seizes  every 
thing  within  its  reach  with  a  spasmodic  effort,  with  violent  at- 
tempts at  inspiration,  accompanied  with  acute  cries  and  smothered 
and  incomplete  wheezings  ;  in  the  meanwhile,  the  face  becomes 
purple  and  tumefied,  the  jugular  veins  are  filled  with  blood,  the 
neck  dilates  with  a  painful  effort,  and  the  limbs  are  stiflened  with 
spasm ;  the  child,  alarmed  at  its  own  distress,  sometimes  loses  its 
consciousness,  and  appears,  from  the  momentary  suspension  of 
breathing,  to  be  dying.  Very  frequently  there  is  no  rale  heard 
during  the  paroxysms  of  coughing,  and  it  is  remarkable  that  the 
more  dry  the  cough  the  more  painful  and  suffocating  it  is ;  it 
becomes  much  less  when  the  mucosities  are  abundant  in  the 
trachea.  All  these  violent  efforts  usually  terminate  in  vomiting, 
by  which  the  child  not  only  throws  up  what  it  had  eaten,  but 
likewise  an  abundance  of  mucosity.  When  the  cough  ceases, 
the  child  recovers  from  its  distress  by  degrees,  remains  exhausted 
for  some  minutes,  and  complains,  if  old  enough,  of  pain  in  the 
forehead  and  sternum ;  its  cry  and  voice  are  feeble ;  but  this 
state  of  fatigue  is  of  short  duration,  for  its  gaiety  soon  returns, 
and  it  enjoys  the  sports  of  its  age  until  prostrated  by  a  new  pa- 
roxysm of  coughing. 

Hooping-cough  continues  for  a  greater  or  less  time  in  the 
acute  state,  such  as  I  have  just  described ;  it  is  often  accompanied 
with  fever,  especially  in  the  commencement,  but  by  degrees  this 
symptom  of  reaction  becomes  less  intense,  or  does  not  appear  at 
all.  This  is  not  the  case,  however,  when  it  is  complicated  with 
pneumonia,  pleurisy,  or  hydrocephalus.  When  hooping-cough 
occurs  in  scrofulous  children,  it  may  hasten  the  disorganization 
which  tubercles  effect,  and  thus  terminate  in  phthisis  of  the 
larynx  or  lungs. 

At  the  end  of  a  few  weeks  or  months,  the  symptoms  diminish 


430  ON   THE    DISEASES    OF    INFANTS. 

in  intensity,  the  expectoration  is  more  abundant,  and  the  muco- 
sity  thicker ;  the  cough  becomes  less  fatiguing,  is  less  intense 
and  less  frequent,  and  finally  disappears  with  the  whole  assem- 
blage of  other  symptoms. 

The  prognosis  of  hooping-cough  is  unfavorable  in  proportion 
to  the  dangerous  nature  of  its  complications  and  the  early  age  of 
the  child.  M.  Guersent  has  correctly  observed  that  in  infants  at 
the  breast  it  is  often  complicated  with  cerebral  congestions,  and 
from  the  first  development  of  this  disease  in  them,  this  complica- 
tion is  quickly  fatal.  We  can  easily  conceive  the  danger  arising 
from  pneumonia,  pleurisy,  softening  of  tubercles,  pneumo-thorax, 
and  other  complications  of  hooping-cough. 

Treatment. — Two  principal  indications  present  themselves  in 
the  treatment  of  this  disease — to  combat  the  inflammation  of  the 
bronchiaB,  and  to  moderate  or  remove  the  nervous  complication. 
It  will  be  necessary,  in  the  beginning  of  the  disease,  to  have  re- 
course to  sanguineous  evacuations,  both  general  and  local,  to  de- 
mulcent drinks,  and  revulsives  to  the  intestinal  tube  ;  in  a  word, 
it  must  be  treated  by  a  purely  antiphlogistic  method,  rigorously 
pursued  during  its  inflammatory  stage  :  as  bronchial  irritations 
will  quickly  produce  in  young  infants  pulmonary  or  cerebral 
congestions,  it  will  be  useful  to  apply  a  few  leeches  to  the  neck, 
or  lateral  parts  of  the  thorax,  upon  the  slightest  symptoms  being 
perceived  of  irritation  in  these  organs.  This  was  the  practice, 
observes  Dr.  Dewees,  of  Willis,  and  appears  to  have  been  the 
general  practice  of  the  age,  and  particularly  of  Sydenham,  As- 
true,  Home,  and  others.  The  success  of  these  celebrated  practi- 
tioners ought  to  induce  us  to  imitate  their  practice.  I  cannot  be- 
lieve it  to  be  a  natural  practice  to  administer  emetics  at  the  same 
time,  in  order  to  relieve  the  stomach  from  the  mucosity  with 
which  it  is  filled.  If  antimony  and  squills  are  to  be  given,  it 
ought  rather  to  be  as  expectorants  than  in  vomiting  doses  ;  as 
half  a  grain  of  kermes,  (sulphuret  of  antimony,)  in  a  two-ounce 
mixture,  for  a  child  of  eight  months  to  a  year  old,  is  suflicient  to 
produce  an  abundant  expectoration.  We  should  remember  that 
very  young  infants  do  not  expectorate,  and  that  it  will  but  fa- 
tigue them  in  vain  to  persevere  in  giving  medicine  of  this  kind. 
The  English  physicians  assert  that  calomel,  given  in  doses  of  a 
few  grains  every  two  or  three  days,  renders  the  progress  of  hooping- 


ON   THE    DISEASES    OP    INFANTS.  431 

cough  more  irregular  and  shorter.  I  can  conceive,  indeed,  without 
partaking  of  their  predilection  for  this  medicine,  that  it  will  accom- 
plish a  good  purpose  in  keeping  the  bowels  open,  and  thus  advan- 
tageously counteract  the  catarrhal  inflammation  of  the  bronchife. 

When  we  are  satisfied  that  the  first  symptoms  of  inflammation 
are  moderated,  and  that  the  nervous  irritation  of  the  bronchias  is 
the  cause  of  the  existing  symptoms,  we  should  endeavor  to  re- 
move it,  and  not  remain  inactive,  which  may  be  fatal  to  the  pa- 
tient, under  the  belief  that  the  hooping-cough  must  run  through 
its  course ;  for  it  is  not  more  dangerous  to  arrest  the  progress  of 
this  disease  than  to  stop  an  intermittent  fever,  the  progress  of  the 
one  requiring  as  much  attention  as  that  of  the  other. 

We  ought,  therefore,  to  avail  ourselves  of  narcotic  and  anti- 
spasmodic remedies  at  the  period  of  the  disease — as  a  demulcent 
mixture,  with  a  quarter  or  half  a  grain  of  the  extract  of  opium,  or, 
what  is  still  better,  one  or  two  drachms  of  syrup  of  poppies.  As- 
safoetida,  given  in  injection,  has  succeeded  in  the  hands  of  some 
practitioners,  but  its  efficacy  is  not  as  yet  sufficiently  demonstra- 
ted. Cullen,  observing  the  periodical  return  of  the  cough,  em- 
ployed cinchona,  but  his  example  has  not  been  followed  by 
others.  Some  advantage  might  be  obtained  from  the  use  of  sul- 
phate of  quinine  in  small  doses  ;  yet  it  must  be  observed  that  the 
remission  is  very  irregular,  and  consequently  we  cannot  foresee 
its  return,  and  might  give  it  even  at  the  moment  the  cough  com- 
mences, which,  without  doubt,  would  interfere  with  the  efficacy 
of  the  remedy.  Hyoscyamus,belladonna,  and  cicuta  have  not  been 
forgotten  among  the  narcotics  used  for  the  treatment  of  hooping- 
cough.  The  powder  of  belladonna,  or  its  gummy  extract,  in 
doses  of  a  quarter  to  half  a  grain  in  any  vehicle,  will  produce 
good  effects,  but  its  operations  are  very  uncertain.  The  sedative 
used  by  M.  Guersent  with  great  advantage,  is  a  mixture  of  equal 
parts  of  oxyde  of  zinc,  belladonna,  and  cicuta,  commencing  with 
a  quarter  of  a  grain  of  these  substances,  given  three  times  a  day, 
and  increasing  it  according  to  the  effect  experienced  from  its 
use.  He  has  also  used  the  oxyde  of  zinc  with  success  in  the  dose 
of  a  grain  every  hour  in  an  infant  of  six  weeks,  where  he  had  in 
vain  attempted  to  arrest  the  paroxysms  of  coughing.* 

*  Guersent,  article  Coguduche,  in  the  Diet,  de  med,,  t.  vi.  p,  20. 


432  ON    THE    DISEASES    OF    INFANTS. 

We  should  also  use  counter  irritants  to  the  skin,  when  the  dis 
ease  exhibits  no  more  sign  of  active  inflammation.  Blisters  be- 
tween the  shoulders,  camphorated  and  ammoniated  frictions  on 
the  arms  or  lateral  parts  of  the  chest,  may  perhaps  be  of  some 
utility.  Without  endeavoring  to  accomplish  the  end  for  which 
Authenrieth  has  advised  frictions  with  his  ointment,  we  may 
nevertheless  use  it  as  a  simple  revulsive ;  the  epigeistrium  or  tho- 
rax may  be  rubbed  with  an  ointment  composed  of  one  part  and 
a  half  of  tartar  emetic  to  eight  parts  of  the  lard  ;  care  must  be 
taken  not  to  rub  the  pustules  already  formed,  for  ulcers  may 
arise  and  cause  fever.  Dr.  Dewees  uses  an  ointment  composed  of 
the  same,  with  the  addition  of  fifteen  drops  of  ol.  lavend.  or  lemon. 

The  state  of  feebleness  in  which  the  child  remains  for  a  long 
time  after  the  hooping-cough  has  disappeared,  requires  the 
greatest  attention  from  the  physician.  Before  using  tonics,  such 
as  the  syrup  or  wine  of  cinchona,  it  will  be  necessary  to  habitn- 
ate  it  gradually  to  nourishment  of  increased  strength,  as  chicken 
water,  veal  or  beef  tea,  animal  jellies,  feculent  vegetables,  and 
only  habituate  it  progressively  to  the  use  of  medicinal  or  other 
wines.  Goats'  milk,  pure  or  diluted,  a  good  nurse,  a  residence 
in  the  country,  particularly  in  the  spring  and  summer,  will  ma- 
terially conduce  to  the  recovery  of  infants  at  the  breast. 

This  is  perhaps  the  proper  place  to  speak  of  nervous  respira- 
tion— such  as  hiccup,  spasm  of  the  glottis,  etc.;  but  as  we  are 
in  possession  of  no  other  than  very  uncertain  data  upon  these  af- 
fections, I  do  not  think  it  necessary  to  devote  a  chapter  to  the 
consideration  of  a  subject  on  which  I  have  nothing  more  to  say 
than  has  already  been  advanced  a  number  of  times.  It  is,  be- 
sides, to  be  remarked,  that  spasm  of  the  glottis  is  often  but  a 
symptom  of  different  inflammatory  diseases  of  which  I  have  al- 
ready spoken. 

I  will  end  this  account  of  the  history  of  diseases  of  the  thorax 
by  observing  that  the  application  of  the  stethoscope  and  percus- 
sion are  neither  so  useless  in  infantile  diseases  or  so  injurious  to 
them  as  M.  Denis  has  asserted  in  his  work,  (page  336,)  or  as  is 
expressed  by  M.  Guersent  in  the  article  Enfant  in  the  Diet,  de 
mod.  We  have  seen  in  this  chapter  that  these  means  may  be 
used  as  a  proper  method  of  investigation  in  the  thoracic  diseases 
of  children. 


ON    THE    DISEASES    OF    INFANTS.  433 


CHAPTER    IX. 


DISEASES    OF   THE    CIRCULATORY    APPARATUS. 

Development  and  congenital  malformation. — The  heart  does 
not  appear  until  some  large  vessels  are  already  formed,  and  the 
vena  porta  usually  exists  before  it.  At  the  commencement  it 
appears  to  be  but  a  swelling  of  this  vein  ;  this  swelling  soon  be- 
comes curved  in  a  semicircle,  presenting  three  dilatations  and 
two  contractions  ;  these  dilatations  are  the  auricles,  left  ventricle, 
and  the  commencement  of  the  aorta ;  they  gradually  disappear 
by  the  approximation  of  the  cavities.  Such,  at  least,  are  the  first 
appearances  of  the  heart  and  vessels  observed  in  the  chick  by 
Haller,  and  in  the  heart  of  the  human  foetus  by  other  experiment- 
ers. In  proportion  as  the  heart  is  developed,  the  various  parts 
composing  it  assume,  by  degrees,  the  form  and  dimensions  which 
they  naturally  have.  Sabatier  and  Wolff  have  seen,  however, 
the  septum  which  separates  the  two  auricles  form,  by  degrees,  but 
having  at  the  period  of  birth  an  opening  by  which  the  blood 
passes  from  the  right  to  the  left  cavities  ;  and  it  appears  that  the 
septum  which  divides  the  two  ventricles  is  formed  by  a  kind  of 
prolongation  which  rises  from  the  base  of  the  left  ventricle,  and 
is  continued  towards  the  summit.  M.  Meckel  has  made  some 
very  interesting  observations  on  the  respective  dimensions  of  the 
cavities  of  the  heart  during  its  formation.  At  first  the  left  ven- 
tricle is  the  largest ;  afterwards  the  same  size  as  the  right ;  and 
then  the  latter,  in  its  turn,  becomes  the  most  voluminous.  The 
auricles  surpass  the  ventricles  in  size  when  the  embryo  is  quite 
young,  but  at  the  time  of  birth  it  is  reversed. 

The  aorta  exists  singly  at  the  seventh  week ;  but  it  soon  ex- 
hibits two  divisions,  the  one  of  which  is  the  pulmonary  artery. 
The  latter,  at  the  fourth  and  fifth  month,  has  branches  which  go 
to  the  lungs,  and  which  are  not  so  voluminous  as  the  arterial 
duct.     All  these  parts  of  the  circulatory  apparatus  are  developed 

55 


434  ON   THE    DISEASES    OF    INFANTS. 

successively,  and  acquire  the  dimensions,  divisions,  and  relations 
which  each  of  these  vessels  have  during  the  remainder  of  life.* 

While  the  heart  is  thus  passing  through  its  various  stages  of 
formation,  it  may  undergo  some  arrest  of  its  development,  which 
will  produce,  at  the  period  of  birth,  and  for  a  long  time  after,  the 
most  serious  symptoms.  I  will  not  stop  to  describe  all  the  mal- 
formations which  the  heart  can  undergo,  for  they  are  of  infinite 
number.  The  most  of  them,  besides,  are  only  developed  in  pro- 
portion as  the  child  advances  in  age,  or  are  the  persistence  of  the 
particular  disposition  of  the  heart  in  new-born  children  ;  so  that 
they  give  rise  to  no  symptom  during  first  infancy,  and  only  man- 
ifest their  existence  by  external  signs  at  a  more  advanced  period 
of  life,  and  do  not  constitute  one  of  the  diseases  of  infancy.  I 
will,  therefore,  confine  myself  to  pointing  out  some  of  the  princi- 
pal malformations  of  the  heart. 

An  entire  absence  of  the  heart  is  only  found  in  acephalous 
children.  It  is  a  rare  thing  to  see  a  single  heart :  that  is  to  say, 
destitute  of  one  of  its  lateral  portions,  and  consequently  present- 
ing only  one  ventricle  and  one  cavity.  I  will  here  record  an  in- 
stance of  this  kind,  the  more  interesting  as  the  description  of 
this  monstrosity  is  accompanied  with  an  account  of  the  symp- 
toms presented  by  the  child  during  life.  This  case  was  commu- 
nicated to  the  Journal  of  Medical  Sciences,  of  Philadelphia,  by 
Dr.  Mauran,  a  physician  residing  at  Providence. 

''"case  LXXVI.— On  the  19th  of  March,  1827,  I  was  requested, 
through  the  parent,  Mr.  A.  B.,  to  examine,  post  mortem,  the  case  of 
his  child,  who  had  died  under  peculiar  and  inexplicable  circumstan- 
ces, the  history  of  which  was  as  follows  :  The  labor  was  natural ; 
the  child,  though  small,  appeared  well  and  healthy  ;  the  respiratory 
apparatus  responded  readily  to  its  natural  stimulus,  and  thus  contin- 
ued while  the  child  remained  in  a  quiescent  state,  but  from  the  change 
of  position  in  washing,  dressing,  etc.,  it  was  noticed  to  be  particularly 
affected.  The  child  experienced  the  greatest  difficulty  on  crying  and 
respiring.  These  symptoms  occurred  occasionally  on  motion,  but 
were  counteracted  by  restoring  the  child  to  a  quiescent  state.  Ten 
days  after  birth  I  was  called  to  revisit  the  patient,  who  w^as  laboring 
under  a  supposed  inflammation  of  the  lungs,  attended  with  a  difficult 
and  apparently  painful  respiration ;  there  was  a  light  fever  and  slight 

♦  Ph.  Beclard,  Embryologie,  p.  84. 


ON    THE    DISEASES    OF    INFANTS.  435 

cough.  I  learned  from  the  nurse  that  the  paroxysms  would  recur  at 
irreo-ular  intervals,  commencing  with  a  convulsive  or  spasmodic  ac- 
tion of  the  whole  chest.  Respiration  was  interrupted,  and  would 
continue  for  many  minutes,  when  the  patient  would  apparently  cease 
to  breathe,  the  whole  surface  to  the  extremities  putting  on  the  above 
described  livid  or  purple  hue — in  fact,  exhibiting  the  perfect  "  puer 
coeruleus." 

By  inclining  the  child  forward  on  the  nurse's  lap,  thereby  afford- 
ing a  pressure  upon  the  chest  and  abdomen,  a  slow  return  of  the 
functions  of  respiration  was  noticed  ;  the  livid  hue  at  the  same  time 
yielding  to  the  improved  circulation,  its  ordinary  healthy  aspect  was 
gradually  restored  to  the  surface.  The  primse  viae  were  directed  to 
be  moderately  evacuated,  slight  pectorals,  with  antispasmodics,  pre- 
scribed, and  perfect  rest  enjoined.  Notwithstanding  these  means,  it 
died  in  one  of  the  paroxysms  we  have  mentioned. 

The  dissection,  fifteen  hours  after  death,  discovered  the  following 
interesting  appearances.  The  child  was  small,  and  exceedingly 
emaciated  ;  surface  yet  livid  ;  abdominal  viscera  perfect.  On  intro- 
ducing a  blow-pipe  into  the  vena  cava  ascendens,  we  could  inflate 
the  whole  viscus  (auricle,  ventricle,  and  coronary  arteries).  The 
heart  being  divided  through  the  ventricle,  vertically  from  its  apex  to 
the  origin  of  the  aorta,  the  following  unique  appearances  were  dis- 
covered. It  was  in  fact  a  single  heart !  having  but  one  auricle  and 
one  ventricle,  communicating  by  a  large  free  foramen,  the  borders 
of  which  gave  origin  to  a  tricuspid  valve.  The  pulmonary  artery 
exhibited  the  most  interesting  feature  of  the  general  malformation  ; 
arising  almost  in  immediate  connection  with  the  aorta  on  its  left 
side,  from  one  common  ventricle,  it  passed  backwards,  giving  out  its 
accustomed  branches,  and  thence  becoming  ductus  arteriosus,  was 
found  pervious  and  opening  into  aorta  descendens.  From  the  fact 
of  the  previous  state  of  this  duct  at  its  aortal  termination,  a  more 
minute  investigation  was  instituted,  which  exhibited  it  perfectly  im- 
pervious at  its  origin,  from  the  ventricle  between  which  and  the  bi- 
furcation was  a  perfect  cul-de-sac.  The  auricle  was  next  observed 
attached  to  the  ventricles  extensively  and  on  its  left  side ;  its  size, 
when  dilated,  being  more  than  two  thirds  that  of  the  ventricle,  and 
exhibiting,  anteriorly,  two  auricular  appendages.  A  vertical  section 
of  the  ventricle  exhibited  the  parietes  unusually  thick  and  strong, 
being  largely  studded  with  the  columnae  carneae.* 

♦  Account  of  a  malformation  of  the  human  heart :  by  J.  Mauran,  M.  D.,  of  Pro- 
vidence, R.  I.    (Philad.  Journ.  Med.  Sciences,  No.  10.) 


436  ON   THE    DISEASES    OF    INFANTS. 

It  is  evident  that  in  this  child  the  blood  could  not  become 
oxygenated  in  sufficient  quantity  to  preserve  life ;  yet  nature 
appears  to  have  made  the  following  provisions  to  supply  the  ab- 
sence of  one  of  the  cavities  of  the  heart,  as  Dr.  Mauran  remarks : 
the  blood  having  arrived  at  the  ventricle,  was  propelled  towards 
the  aorta,  but,  instead  of  coming  to  the  lungs  through  the  pul- 
monary artery,  which  was  obliterated  near  the  heart,  the  lesser 
circulation  was  affected  indirectly  by  a  retrograde  current  through 
the  ductus  arteriosus,  thence  into  the  pulmonary  branches,  to  be 
returned  to  the  ventricle,  the  common  receptacle  of  this  and  of 
the  black  blood  of  the  cavae. 

Instead  of  meeting  with  so  complete  an  absence  of  one  of  the 
lateral  parts  of  the  heart,  there  is  sometimes  only  a  deep  depres- 
sion between  the  two  ventricles,  one  of  which,  much  smaller 
than  the  other,  appears  to  have  been  arrested  in  its  development. 
The  plurality  of  the  heart,  according  to  Meckel,  is  extremely 
rare  in  cases  where  there  is  not  a  duplicate  foetus.  The  develop- 
ment of  the  auricles  is  considerable  in  some  infants.  I  once  saw, 
in  a  little  girl  that  died  some  days  after  birth,  a  pointed  prolon- 
gation of  the  right  auricle,  of  about  an  inch  long ;  it  hung  loose 
in  the  pericardium  in  front  of  the  heart.  The  excessive  size  of 
the  heart  may  perhaps  be  owing  to  a  malformation. 

Narrowness  of  the  auriculo-ventricular  or  vascular  orifices,  is 
scarcely  observed  at  the  period  of  birth  ;  but  in  proportion  as  the 
child  ad\rances  in  age,  if  the  size  of  the  orifices  do  not  follow  the 
progress  of  the  cardiac  development,  there  is  then  a  greater  or 
less  disturbance  in  the  functions  of  the  circulatory  apparatus ; 
producing  several  disorders,  designated  by  authors  under  the 
general  term  of  asthma.  Lastly,  we  must  mention,  also,  among 
the  congenital  malformations  of  the  heart,  the  irregular  insertion 
of  the  large  vessels,  the  transposition  of  the  organ  to  the  right 
side  of  the  chest,  a  deviation  of  more  frequent  occurrence  than 
is  generally  believed,  and  of  which  M.  Baron  has  presented  seve- 
ral instances  to  the  Academic  Royale  de  Medecine.  Besides 
these,  there  are  several  organic  aberrations  of  the  principal  organs 
of  circulation  in  an  infant  at  birth — too  many  for  enumeration 
here.  The  symptoms  of  the  greater  part  of  these  organic  devia- 
tions which  have  been  mentioned  occurring  at  birth,  are,  defect 
of   haematosis,   suftbcation,  irregular  pulsations  of  the  heart, 


ON    THE    DISEASES    OF    INFANTS.  437 

cerebral    and    pulmonary  congestions,  and,    very  frequently, 
death. 

Soon  after  birth,  the  circulatory  apparatus  undergoes  altera- 
tions of  the  greatest  importance,  not  only  in  its  organization,  but 
also  in  its  functions  ;  and  it  is  to  these  changes  that  the  many 
affections  peculiar  to  infants  are  to  be  attributed  ;  but  in  order  to 
understand  precisely  the  modifications  of  the  circulatory  appa- 
ratus may  be  a  cause  of  the  many  morbid  symptoms  in  young 
infants,  it  appears  to  me  necessary  to  follow  with  care  the  pro- 
gress of  the  organic  and  functional  changes,  in  order  to  appre- 
ciate properly  the  influence  they  may  exert  upon  the  health  of 
the  child.  I  will  therefore  divide  this  chapter  into  two  articles  : 
the  one  treating  of  the  establishment  of  the  circulation,  the  other 
of  the  diseases  of  the  circulatory  apparatus. 

Art.  I. — Of  the  establishment  of  independent  circulation. 

I  have  studied  with  the  greatest  care  the  changes  which  occur 
in  the  heart,  ductus  arteriosus,  ductus  venosus,  and  umbilical  ar- 
teries, during  the  first  days  of  extra-uterine  life,  and  shall  exhibit 
here  the  results  of  these  researches. 

I  shall  consider  successively — 1st,  The  period  at  which  the- 
foetal  openings  are  obliterated  ;  2dly,  Their  mode  of  obliteration  ; 
3dly,  I  will  exhibit  the  physiological  and  pathological  conse- 
quences which  naturally  flow  from  these  researches. 

§1.  Period  of  the  obliteration  of  the  fcetal  open- 
ings.— Infants  of  the  age  of  07ie  day. — In  nineteen  children 
aged  one  day,  there  were  fourteen  in  whom  the  foramen  ovale 
was  completely  open  ;  in  two  of  them  it  had  begun  to  be  oblitera- 
ted; and  in  two  it  was  entirely  closed.  Consequently  no  blood 
passed  through  it. 

In  the  same  children,  the  ductus  arteriosus  was  free  and  filled 
with  blood  in  thirteen  ;  its  obliteration  had  commenced  in  four  : 
and  in  the  remainder  it  was  completely  obliterated.  I  also  no- 
ticed that  in  one  of  the  last  mentioned  children  there  was  a  com- 
plete occlusion  of  the  foramen  ovale.  In  the  other  children  in 
the  same  state,  the  ductus  arteriosus  was  still  open. 

With  respect  to  the  umbilical  arteries,  they  were  still  open  near 
their  junction  with  the  iliac  arteries,  but  their  calibre  was  nar- 
rowed in  consequence  of  a  very  remarkable  thickening  in  their 


438  ON   THE    DISEASES    OF    INFANTS. 

walls.  In  all  these  children,  the  umbilical  vein  and  ductus  veno- 
suswere  free,  and  the  latter  was  most  generally  gorged  with  blood. 

From  this  examination  it  appears  that  the  foramen  ovale  and 
ductus  arteriosus  are  still  open  on  the  first  day  of  birth  in  most 
instances,  although  they  may  be  obliterated  at  this  period. 

Infants  of  the  age  of  two  days. — In  twenty-two  children, 
aged  two  days,  there  were  fifteen  where  the  foramen  ovale  was 
perfectly  open  ;  in  three  of  them  it  was  almost  obliterated  ;  and 
in  four  entirely  closed.  In  thirteen  of  these  children  I  found  the 
ductus  arteriosus  still  open  ;  in  six  the  obliteration  had  commen- 
ced ;  and  in  three  was  entirely  obliterated.  In  all,  the  umbilical 
arteries  were  obliterated  to  a  greater  or  less  extent,  but  the 
umbilical  vein  and  ductus  venosus,  although  empty  and  flatten- 
ed, would  not  allow  of  the  passage  of  a  moderate  sized  stylet. 
These  facts  are  sufficient  to  demonstrate  that,  in  most  instances, 
the  foramen  ovale  and  ductus  arteriosus  are  not  obliterated  on 
the  second  day  after  birth,  although  the  child  may  enjoy  inde- 
pendent life  ;  as  to  the  umbilical  arteries,  having  now  become 
useless,  they  undergo  the  changes  resulting  from  their  default  of 
action. 

Infants  of  the  age  of  three  days. — I  also  subjected  the  bodies 
of  twenty-two  children  aged  three  days  to  the  same  examination. 
In  fourteen  of  these  the  foramen  ovale  was  still  open ;  in  five, 
the  obliteration  had  already  commenced,  and  was  complete  in 
the  remaining  three. 

The  ductus  arteriosus  was  also  open  in  fifteen  ;  the  obliteration 
had  commenced  in  five,  and  was  complete  in  two.  Both  of  these 
subjects  also  presented  the  closure  of  the  foramen  ovale.  The 
umbilical  vessels  and  the  ductus  venosus  were  empty  and  obli- 
terated in  all  these  subjects.  Now  it  is  evident  that  these  ves- 
sels are  obliterated  before  the  foramen  ovale  and  ductus  arterio- 
sus have  undergone  any  complete  occlusion,  and  it  can  therefore 
be  asserted,  that  at  the  third  day  the  ductus  arteriosus  and  fora- 
men ovale  are  not  generally  closed. 

Infants  of  the  age  of  four  days. — I  found  in  twenty-seven 
children,  aged  four  days,  the  foramen  ovale  open  in  seventeen. 
In  these  seventeen  cases,  there  were  six  where  this  opening  was 
very  large,  and  distended  with  a  considerable  quantity  of  blood ; 
and  in  the  remaining  number  it  was  slightly  open.    In  the 


ON   THE    DISEASES    OF    INFANTS.  439 

twenty-seven  cases  now  under  consideration,  the  closure  of  this 
opening  had  commenced  in  eight,  and  it  was  completely  closed 
in  two. 

The  ductus  arteriosus  was  still  open  in  seventeen  children ; 
its  obliteration  had  begun,  and  it  exhibited  nothing  more  than  a 
small  hole  in  seven  of  these,  and  its  closure  was  complete  in 
three ;  the  umbilical  arteries  in  almost  all  were  obliterated  near 
the  umbilicus,  but  still  susceptible  of  dilatation  near  the  junction 
with  the  iliac  arteries.  The  umbilical  vein  and  the  venous 
canal  were  completely  empty,  and  considerably  contracted. 

Infants  of  the  age  of  five  c?a?/5.— Twenty-nine  children,  aged 
five  days,  were  subjected  to  the  same  examination  as  in  the 
preceding  instance ;  thirteen  exhibited  the  foramen  ovale  still 
open  ;  but  this  opening  did  not  exist  in  the  same  degree  in  all. 
It  was  largely  dilated  in  four  individuals,  and  in  ten  others  its 
diameter  was  much  smaller. 

This  passage  was  almost  completely  obliterated  in  ten  individ- 
uals, and  in  six  others  sufficiently  so,  as  to  leave  no  communi- 
cation between  the  auricles. 

I  found,  in  these  twenty-nine  cases,  tlie  ductus  arteriosus  open 
in  fifteen ;  in  these  fifteen  there  were  ten  where  the  duct  was 
very  large.  The  obliteration  had  made  considerable  progress  in 
the  remaining  five ;  and  was  almost  complete,  or  at  least  the 
calibre  of  the  duct  consisted  of  nothing  more  than  a  narrow  hole, 
in  seven ;  and  in  seven  others  the  obliteration  was  complete.  As 
to  the  umbilical  vessels,  their  obliteration  was  complete  in  all. 

We  have  seen,  thus  far,  that  the  foetal  openings  remained  free 
in  a  number  of  children  five  days  after  their  birth.  None  of 
the  children  exhibited  any  peculiar  symptoms  which  appeared 
to  have  their  seat  in  the  circulatory  apparatus.  We  shall  find 
the  number  diminish  in  subjects  of  more  advanced  age  than 
those  which  have  already  been  the  object  of  our  researches. 

Infants  of  the  age  of  eight  days. — I  have  not  observed  any 
well-marked  difference  between  children  of  six  or  seven  days, 
and  those  which  we  have  just  described.  This  remark,  how- 
ever, is  not  applicable  to  those  of  eight  days.  Indeed,  I  have 
found  but  five  where  the  foramen  ovale  was  still  open  in  twenty 
cases  that  I  examined.  It  was  partially  closed  in  four  individu- 
als, and  its  occlusion  was  complete  in  eleven. 


440  ON   THE    DISEASES    OF    INFANTS. 

In  these  twenty  children  there  were  but  three  in  whom  the 
ductus  arteriosus  was  not  yet  obliterated ;  one  of  them  presented 
an  aneurism  of  the  duct,  of  the  size  of  a  hazelnut ;  interiorly  it 
was  covered  with  a  thick  layer  of  a  yellow  color  and  fibrinous 
consistence,  analogous  in  every  respect  to  those  fibrous  layers 
which  cover  the  interior  of  an  aneurismal  pouch. 

In  these  twenty  individuals,  I  found  in  six  the  ductus  arterio- 
sus almost  entirely  obliterated,  and  its  obliteration  was  complete 
in  eleven.  The  umbilical  vessels  were  perfectly  closed  in  almost 
all ;  I  say  in  almost  all,  because  I  observed  neither  the  umbilical 
arteries  nor  vein  in  five  of  them. 

From  the  last  examination,  it  appears  that  the  foetal  openings 
are  usually  obliterated  on  the  eighth  day,  but  they  may  yet  be 
found  open  even  at  that  period ;  I  will  also  add  that  even  on  the 
twelfth  and  fifteenth  day,  and  in  the  third  week,  the  foramen 
ovale  or  ductus  arteriosus  may  still  be  open  without  the  child 
experiencing  any  particular  symptom  ;  for  I  will  again  observe 
that  I  have  chosen  for  these  researches  children  who  for  the 
most  part  died  from  afiections  in  which  the  respiratory  apparatus 
did  not  participate. 

From  this  exposition,  it  is  evident  that  the  foetal  openings  are 
not  obliterated  immediately  after  birth  ;  that  the  period  at  which 
this  occurs  is  extremely  variable,  yet  the  foramen  ovale* and 
ductus  arteriosus  are  usually  closed  on  the  eighth  or  tenth  day. 
It  results  also  from  the  examination  which  we  have  made,  that 
the  modifications  which  follow  the  cessation  of  foetal  life,  in  the 
circulatory  organs  of  a  new-born  child,  occur  in  the  following 
order :  the  umbilical  arteries  are  first  obliterated,  then  the  vein, 
next  the  ductus  arteriosus,  and  lastly  the  foramen  ovale.  The 
persistence  then  of  the  foetal  openings  for  some  days  after 
birth  ought  not  to  be  considered  as  a  disease,  since  it  is  not  un- 
common to  meet  with  it  without  having  given  rise  to  any  par- 
ticular symptom.  This  irregularity  or  tardiness  is  attributable, 
as  will  be  presently  seen,  to  the  mode  of  obliteration. 

§  II.  Mode  of  obliteration  of  the  fcetal  openings. — 
When  the  arrangement  which  gradually  occurs  in  the  foramen 
ovale  from  the  earliest  months  of  conception  until  the  period  of 
birth  is  examined,  it  will  be  perceived  that  the  form  of  this  open- 
ing and  the  disposition  of  the  surrounding  parts,  and  particu- 


ON    THE    DISEASES    OF    INFANTS.  441 

larly  that  of  the  Eustachian  valve,  are  such  that  the  blood, 
which  at  first  flows  without  any  obstacle  from  one  auricle  to  the 
other,  by  degrees  experiences  some  difiiculty  in  its  passage.  Sa- 
batier  especially  has  remarked  this.  Thus  the  first  modification 
in  the  organization  of  the  heart  forces  the  blood  to  change  its 
course  ;  this  fluid,  in  itself  inert,  is  under  the  immediate  depend- 
ance  of  the  moving  power  which  projects  and  directs  it  through 
the  proper  passage.  If  this  be  so,  it  must  also  follow  that  in 
those  parts  which  the  blood  leaves,  an  anatomical  modification 
occurs,  which  changes  the  form  and  modifies  the  action  of  these 
organs,  and  produces,  in  the  blood  Avhich  flows  through  them,  a 
change  of  direction.  Now  if  the  umbilical  arteries  and  the  ar- 
terial duct  are  examined,  in  proportion  as  they  become  oblite- 
rated, it  will  be  seen  that  their  walls  gradually  become  thickened. 
The  thickening  of  the  umbilical  arteries  is  more  remarkable  at 
the  point  of  insertion  at  the  umbilicus,  at  which  part  they  ex- 
hibit a  kind  of  swelhng  which  very  materially  affects  the  calibre 
of  the  artery,  and  this  swelling  appears  to  be  the  result  of  a  spe- 
cies of  hypertrophy  of  the  yellow  elastic  fibrous  tissue ;  whence 
it  follows  that  the  artery  exercises  at  this  part  a  contractile  force 
superior  to  the  dilating  power  of  the  blood  propelled  by  the  iliac 
arteries.  It  is  very  easy  to  prove  the  thickness  of  the  walls  of 
the  artery  by  cutting  it  in  sections  at  this  part ;  the  thickness,  it 
will  be  also  perceived,  diminishes  in  proportion  as  we  approach 
the  iliac  arteries,  and  it  is  precisely  in  this  direction  that  the  pro- 
gress of  the  obliteration  is  observed  to  occur  after  birth.  Two 
conditions,  therefore,  cause  the  blood  after  birth  to  leave  the 
course  it  had  while  in  the  uterus  :  1st,  the  estabhshment  of  res- 
piration and  the  pulmonary  circulation ;  2dly,  the  modification 
of  texture  occuring  in  the  umbilical  arteries. 

The  following  phenomenon  proves  also  that  the  contractility 
of  the  umbilical  vessels  is  susceptible  of  suspending  the  course 
of  the  blood  in  them ;  if  the  umbilical  cord  be  cut  at  some  dis- 
tance from  the  umbilicus  at  the  time  of  birth  in  a  plethoric  child, 
the  blood  will  at  first  be  seen  to  issue  in  a  jet  with  considerable 
force,  then  becoming  slower,  and  afterwards  stopping  altogether ; 
if  another  portion  of  the  cord  be  cut  another  jet  of  blood  occurs, 
and  soon  stops.  This  hemorrhage  may  be  renewed  at  each  sec- 
tion of  the  cord.     M.  P.  Dubois  has  informed  me  that  he  has 

5G 


442  ON   THE    DISEASES    OF    INFANTS. 

seen  this  frequently  occur.  Now  the  course  of  the  blood  is  in 
some  degree  arrested,  because  the  umbiUcal  arteries  contract  on 
it  and  force  it  to  retrogade  ;  if  there  exist  near  the  umbilicus 
and  within  the  abdomen  a  portion  of  the  umbilical  arteries  more 
contractile  from  the  existence  of  a  greater  quantity  of  elastic 
fibrous  tissue,  it  can  easily  be  conceived  that  the  course  of  the 
blood  in  the  child  becoming  less  quick  when  the  calm  which 
occurs  after  birth  begins  to  be  established,  these  arteries  may 
have  power  to  resist  from  the  first  the  progress  of  the  blood  ;  in 
proportion  as  the  child  advances  in  age,  the  artery  becomes 
more  obliterated,  and  undergoing  a  kind  of  traction  from  the 
progressive  widening  of  the  abdominal  parietes,  it  loses  altogether 
its  vascular  form,  and  is  transformed  into  a  true  ligament. 

What  is  observed  in  these  arteries  occurs  also  in  the  ductus 
arteriosus.  In  the  embryo  it  is  as  flexible  as  the  other  arteries, 
and  is,  therefore,  as  easily  dilated  by  the  column  of  blood  which 
flows  through  it,  which  penetrates  without  any  obstacle  into  the 
aorta ;  but  at  birth,  and  after  this  period,  the  walls  of  this  duct 
become  gradually  thicker,  and  a  sort  of  concentric  hypertrophy 
is  developed  in  them,  Which,  without  diminishing  in  appearance 
the  size  of  the  vessels,  nevertheless  produces  a  contraction  of  its 
calibre,  by  which  the  blood  driven  from  this  duct  passes  through 
the  pulmonary  arteries.  "When  the  ductus  arteriosus  has  under- 
gone this  hypertrophy  and  obliteration,  I  cannot  describe  it  bet- 
ter than  by  comparing  it  to  a  tube,  the  circumference  of  which  is 
very  thick,  and  that  presents  in  its  centre  nothing  more  than  a 
small  hole.* 

The  obliteration  of  the  vein  and  duct  does  not  occur  in  the  same 
manner.  These  vessels  do  not  exhibit,  as  do  the  others,  any  re- 
markable thickening  of  their  walls ;  the  moment  the  umbilical 
cord  is  cut,  the  vein  is  no  longer  susceptible  of  receiving  blood  in 
its  calibre,  at  least  except  by  regurgitation,  from  the  vena  cava. 
The  sides  collapse  and  approach  each  other ;  they  thus  come  in 

*  These  observations  are  confirmed  by  those  made  previously  by  Dr.  Berndt,  of  Vi- 
enna, professor  of  legal  medicine,  relative  to  the  changes  which  the  ductus  arteriosus 
undergoes  after  birth, — changes  on  which  the  German  professor  has  founded  his  most 
conclusive  proofs  of  the  persistance  of  life  after  the  birth  of  the  child.  The  hist  017  of 
the  closure  of  the  foetal  vessels  has  been  also  considered  by  Careano,  Trew,  etc.  V. 
th^  article  of  Dr.  Robert  Arrowsmith  on  this  subject,  in  the  Journ.  Hebdom.  de  med.^ 
t.  iii.,  1829.  ' 


ON   THE    DISEASES    OF    INFANTS.  443 

contact,  and  the  passage  is  at  last  obliterated,  as  is  seen  in  all 
tubes  of  every  character  as  soon  as  they  no  longer  give  pas- 
sage to  the  fluid  usually  passing  through  them.  Yet  they  still 
preserve  for  a  long  time  a  free  passage,  for  they  may  easily 
be  distended  by  introducing  into  them  an  ordinary  sized  sty- 
let, while  this  is  not  the  case  with  the  arteries.  In  the  arte- 
ries there  is,  if  I  may  be  allowed  the  expression,  an  active  oblite- 
ration ;  the  blood  has  been  forced  to  abandon  them  by  a  succes- 
sion of  organic  modifications  occurring  in  the  texture  of  their 
walls,  while  in  regard  to  the  umbilical  vein  and  venous  duct, 
there  is  a  passive  obliteration — that  is  to  say,  it  follows  the  ab- 
sence of  the  blood ;  it  is  the  result  and  not  the  cause  of  the  retro- 
pulsion  of  the  sanguineous  fluid.  This  difference  doubtless  de- 
pends on  the  difference  of  organization  between  the  arterial  and 
venous  system.  If  it  be  necessary  that  the  foramen  ovale  and 
ductus  arteriosus  should  undergo  organic  changes  for  their  oblit- 
eration, it  will  be  easily  understood  that  nature,  sO  fertile  in 
anomalies,  may  prepare  these  modifications  either  prematurely 
or  tardily ;  hence  the  cause  of  the  obliteration  of  the  foetal  open- 
ings from  the  first  in  some  children,  and  the  persistance  of  the 
foramen  ovale  and  ductus  arteriosus  in  others,  to  a  period  far  re- 
moved from  birth.  Hence  also  the  necessity  of  a  greater  or  less 
time  in  most  cases  for  the  completion  of  this  obliteration.  In  this 
manner  can  be  explained  the  irregularities  of  the  period  of  the 
complete  establishment  of  the  independent  circulation,  without 
the  necessity  of  considering  them  as  the  cause  or  effect  of  certain 
diseases  of  the  heart  or  lungs. 

The  accomplishment  of  these  phenomena  of  transition  must 
doubtless  be  attended  with  an  incomplete  oxygenation  of  blood, 
since  all  this  fluid  which  the  heart  propels  to  the  different  parts 
of  the  body  has  not  passed  through  the  lungs.  But  after  all,  is  it 
necessary  that  the  blood  of  an  infant  just  born  should  be  oxyge- 
nated, equally  with  that  which  passes  through  the  arteries  of  an 
adult  ?  Would  it  not  rather  appear  that  the  tender  frame  of  a 
new-born  child  ought  not  to  receive  blood  possessing  too  much 
stimulating  properties,  that  the  materials  of  nutrition  should  not 
be  too  suddenly  charged  with  exciting  principles,  the  action  of 
which  on  the  organs  of  an  infant  may  be  injurious  to  its  health, 
and  to  the  progressive  establishment  of  independent  life  ?     I  am 


444  ON   THE    DISEASES    OF    INFANTS. 

of  this  opinion,  and  do  not  think  its  correctness  can  be  denied, 
flowing  as  it  does  from  the  anatomical  examination  of  the  circu- 
latory organs  of  a  young  child.  This  assertion  is  supported  by 
another  remark, — the  lungs  would  be  exposed  to  fatal  congestions 
if  the  pulmonary  arteries  should  suddenly  throw  into  them  all 
the  blood  which  flows  into  the  heart.  The  ductus  arteriosus,  by 
permitting  the  blood  to  pass  through  it,  comes,  as  it  were,  to  the 
aid  of  the  respiratory  organs,  the  congested  state  of  which  will 
not  permit  the  air  to  arrive  freely  in  the  cells  ;  the  establishment 
of  independent  life  is,  therefore,  acutally  promoted  by  the  contin- 
uance of  fostal  life.  Thus,  then,  there  is  a  connection  between 
the  organization  and  disposition  of  parts,  and  the  exercise  of 
their  functions,  and  they  follow  in  a  regular  order,  and  by  tran- 
sitions prepared  by  nature,  to  the  end  that  no  sudden  and  unex- 
pected change  may  interrupt  the  order  and  harmony  of  the  phe- 
nomena of  life.  If  these  openings  continue  beyond  the  period 
we  have  indicated,  they  may  be  followed  by  diseases  which  we 
shall  consider  in  the  following  article. 

Art.  2. 
§  I.  Diseases  of  the  heart  and  large  vessels. 

Diseases  of  the  heart  in  young  infants,  as  in  adults,  consist  for 
the  most  part  in  organic  lesions,  existing  at  birth,  but  the  effects 
of  which  are  not  manifested  until  a  more  advanced  age.  The 
history  of  diseases  of  the  heart  does  not  then  belong  exclusively 
to  the  pathology  of  children  at  the  breast.  I  shall  therefore  con- 
fine myself  to  the  consideration  of  those  affections  of  the  centre 
of  circulation  which  are  the  most  frequently  met  with  in  young 
infants. 

The  persistance  of  the  inter-auricular  orifice  and  ductus  arte- 
riosus does  not  produce,  as  we  have  just  seen,  any  particular 
symptoms  during  the  first  days  of  life,  provided  it  does  not  op- 
pose the  perfect  oxygenation  of  the  blood.  But  if.  at  the  same 
time,  there  exist  a  considerable  sanguineous  plethora,  this  mal- 
formation, joined  to  the  impossibility  or  extreme  difficulty  of  the 
establishment  of  respiration,  hinders  the  oxygenation  of  the 
blood,  producing  the  disease  known  by  the  name  of  cyanosis. 

Cyanosis — cyanopathia.  as  M.  Marc  proposes  to  denominate 


ON   THE    DISEASES    OF    INFANTS.  445 

it, — is  a  disease  which  may  be  observed  at  all  ages,  and  upon  the 
nature  of  which  Corvisart,  M.  Gintrac,  and  M.  Marc  have  pub- 
lished some  interesting  refiections,  is  not  the  constant  result  of 
the  pcrsistance  of  the  foramen  ovale,  nor  of  the  passage  of  venous 
blood  into  the  arterial  system,  since  there  are  a  number  of  exam- 
ples of  malformation  of  the  circulatory  apparatus  existing  which 
might  have  produced  this  phenomenon  without  its  ever  having 
appeared.  But  this  blue  coloring  of  the  integuments  is  probably 
owing  to  the  mixture  of  the  two  kinds  of  blood,  or  to  a  defect  in 
the  oxygenation  of  the  arterial  blood,  either  on  account  of  the  ex- 
istence of  a  communication  between  the  two  lateral  cavities,  or 
of  its  incomplete  oxygenation  in  the  lungs.  Thus  it  is  not  sur- 
prising to  find  in  an  infant  born  in  a  state  of  threatened  as- 
phyxia, and  in  whose  lungs  the  air  has  not  penetrated,  a  sort  of 
transient  cyanopathia,  which  disappears  immediately  upon  the 
complete  establishment  of  respiration.  Corvisart  has  very  hap- 
pily described  the  resemblance  between  the  coloring  of  a  new- 
born child  with  incomplete  respiration,  and  that  of  an  adult 
whose  heart  exhibits  malformations  or  organic  lesions,  which 
embarrass  or  suspend  the  normal  course  of  the  blood.  "  In  com- 
paring," says  this  illustrious  physician,  "  the  effects  produced  by 
the  communication  established  between  the  right  and  left  cavities 
of  the  heart  with  those  immediately  resulting  from  various 
species  of  asphyxia,  do  they  not  exhibit  a  striking  analogy  ?  Ts 
there  not  something  equally  remarkable  between  this  state  and 
that  which  is  seen  in  some  children  after  birth,  especially  after  a 
more  or  less  tedious  labor  ?  The  face  has  more  or  less  a  blue- 
violet  color,  and  even  the  body  presents  the  same  tint  sometimes 
to  a  high  degree;  in  all,  the  body  is  cold  to  the  touch." 

In  considering  the  apparently  contradictory  facts  published  on 
the  subject  of  cyanosis,  by  Buret,  Corvisart,  M.  Marc,  M.  Bres- 
chet,  M.  Fouquier,  etc.,  I  think  it  in  our  power  to  draw  a  conclu- 
sion of  a  middle  character  between  that  opinion  which  regards 
the  affection  as  the  result  of  a  malformation  of  the  heart  and  the 
opposite ;  it  is,  that  cyanosis  being  to  all  appearance  the  effect  of 
a  want  of  oxygenation  of  the  venous  blood,  it  may  exist  with  or 
without  a  malformation  of  the  heart,  provided  the  blood,  in  pass- 
ing through  the  lungs,  does  not  undergo  the  vital  and  chemical 
modifications  which  naturally  occurs  in  them.     If,  notwithstand- 


446  ON    THE    DISEASES    OF    INFANTS. 

ing  the  communication  between  the  auricles,  cyanosis  does  not 
take  place,  it  is  because  the  blood  passing  through  the  lungs  is 
in  sufficient  quantity,  and  sufficiently  oxygenated  to  impart  its 
oxygenation  to  the  venous  blood  with  which  it  is  mixed.  On  the 
other  hand,  if  the  cavities  of  the  heart  are  in  a  normal  state,  but 
the  peculiar  disposition  of  the  lungs  does  not  permit  the  oxygen 
of  the  air  to  transform  the  venous  into  arterial  blood,  cyanosis 
will  be  the  result.  Whence  it  follows  that  this  disease  is  always 
an  indication  of  a  defect  in  the  oxygenation  of  the  blood,  whether 
there  exist  a  malformation  of  the  heart  or  not.  Do  we  not  see  in 
infants  in  whom  the  pulmonary  circulation  is  intercepted  by  an 
engorgement  or  an  inflammation  of  the  lungs,  the  alee  of  the 
nose,  the  lips,  the  face,  and  even  the  extremities  become  bluish — 
the  first  degree  of  cyanosis  ?  And  while  children  affected  with 
pneumonia  are  i7i  articulo  mortis,  is  it  not  very  common  to  see 
every  part  of  the  body  become  livid  and  blue  ?  The  cause  of 
cyanosis  may,  therefore,  consist  in  a  malformation  of  the  heart, 
complicated  with  congestion  or  inflammation  of  the  lungs,  or  in 
an  affection  of  the  lungs  without  organic  lesion  of  the  heart ; 
and  in  every  instance  where  it  exists,  if  the  functions  of  the 
lungs  are  performed  freely,  cyanosis,  it  is  evident,  cannot  occur, 
because  the  venous  blood  receives^  by  its  mixture  with  the  arte- 
rial, a  portion  of  its  chemical  and  vital  properties,  which  it 
needed. 

This  explanation  is  applicable  to  a  great  number  of  cases,  but 
it  is  necessarily  liable  to  many  exceptions  ;  it  cannot,  for  instance, 
explain  the  remarkable  fact  pointed  out  by  M.  Breschet,  who 
saw,  in  a  child  about  a  month  old,  the  left  subclavian  artery  arise 
from  the  pulmonary  artery,  without  causing  the  slightest  change 
of  color  in  the  left  arm,  which  received  no  other  than  venous 
blood.* 

Local  or  general  cyanosis,  however,  in  most  instances,  in  new- 
born children,  is  the  effect  of  a  sanguineous  congestion  about  the 
heart  or  lungs,  and  the  best  method  of  relieving  it  is  that  recom- 
mended by  Corvisart,  to  hold  the  child  near  the  fire,  and  to  rub 
gently  the  head  and  body  with  hot  cloths.  This  should  be  per- 
severing] y  continued,  and  is  much  better  than  all  the  aspersions 

♦  Ferrus,  art.  Cyanose,  Diet,  dt  med.,  in  21  vol. 


ON    THE    DISEASES    OP    INFANTS.  447 

recommended  by  accoucheurs.*  When  it  is  the  eifect  of  pneu- 
monia, the  proper  means  for  treating  this  inflammation  must  be 
adopted,  of  which  it  is  only  a  symptom. 

It  is  rare  to  see  in  children  at  the  breast  the  different  kinds  of 
aneurism  which  are  so  frequently  met  with  in  more  advanced 
age.  In  general,  the  right  cavities  of  the  heart  exhibit  at  birth 
the  difference  of  capacity  which  they  have  with  reference  to  the 
left  cavities  during  life  ;  this  at  least  is  true  with  respect  to  most 
of  the  infants  which  I  have  dissected.  Yet  I  have  often  seen  two 
ventricles  of  the  same  width  and  same  thickness  of  the  walls ; 
but  this  is  much  more  rare  than  the  preceding. 

I  have  seen  but  one  case  of  passive  dilatation  of  the  cavities  of 
the  heart  in  an  infant  at  the  breast.  This  case  appeared  to  me 
the  more  interesting,  as  the  child  exhibited  symptoms  analogous 
to  those  which  are  observed  in  adults  similarly  affected. 

CASE  LXXVII. — Passive  aneurism  of  the  heart. — Marie  Llie- 
ritier,  aged  two  days,  of  a  good  constitution,  entered  the  infirmary 
on  the  1st  of  September.  It  was  observed  that  this  child  was  fre- 
quently attacked  with  syncope,  prolonged  to  so  great  a  length  of 
time  as  to  produce  a  belief  sometimes  that  she  was  dead.  The  pul- 
sations of  the  heart  were  usually  obscure,  slow,  and  irregular ;  the 
cry  was  strong  and  complete,  the  percussion  of  the  thorax  very  so- 
norous, and  respiration  could  be  heard  in  every  part.  As  there  was 
no  other  symptom  present,  she  was  placed  under  the  care  of  the  or- 
dinary nurses,  in  whose  charge  she  remained  until  the  end  of  Octo- 
ber. The  symptoms  of  which  I  have  spoken  became  more  fre- 
quent, and  she  re-entered  the  infirmary,  presenting  a  considerable 
emaciation ;  respiration  was  extremely  difficult,  labored,  and  occa- 
sionally suffocating;  there  was  a  bluish  coloring  about  the  alae  of  the 
nose  and  lips,  and  the  syncope  occurred  two  or  three  times  a  day. 
The  pulse  was  small  and  irregular  ;  extremities  cold  and  cedema- 
tous  ;  cry  distressing,  and  as  if  dying.  Death  occurred  on  the  2d  of 
November,  while  vomiting  brown  and  bloody  matters. 

On  opening  the  body,  there  was  found  a  general  discoloration  of 
the  mucous  membrane  of  the  intestines,  on  the  surface  of  which 
there  was  exhaled  some  black  fluid  blood.  Some  tumefied  follicular 
plexuses  existed  in  the  ileo-caecal  region. 

The  posterior  border  and  the  inferior  lobe  of  the  right  lung  were 

*  Corvisart,  loc.  cit.  ^  . 


448  ON   THE    DISEASES    OF    INFANTS. 

hepatized ;  the  ductus  arteriosus  was  obliterated ;  the  heart  was 
about  the  size  of  a  hen's  egg ;  the  ventricle  and  the  auricle  of  the 
right  side  formed,  as  it  were,  the  volume  of  the  organ.  Their  cavi- 
ties were  very  much  dilated,  and  their  walls  almost  as  thin  as  a  sheet 
of  paper,  whilst  the  opposite  cavities  were  very  much  contracted, 
and  their  walls  hypertrophied ;  the  inter-auricular  orifice  was  almost 
entirely  obliterated  ;  the  orifices  and  valves  of  the  heart  were  free  ; 
the  brain  was  very  firm  and  much  injected. 

It  is  probable  that  the  dilatation  of  the  right  cavities  of  the 
heart  of  this  child  resulted  from  the  hypertrophy  and  contrac- 
tion of  the  left,  which  did  not  receive  the  blood,  that  was 
obliged  to  reflow  into  the  opposite  ventricle  and  auricle,  and  thus 
inordinately  distend  them.  There  occurred  in  this  case  that 
which  is  observed  in  adults  v/ho  exhibit  contractions  or  calcare- 
ous productions  at  the  valves  or  orifices  of  the  ventricles  or 
auricles. 

I  have  not  seen  an  aneurism  of  the  large  vessels  at  this  early 
age.  Once,  however,  I  saw  in  a  child  of  eight  months,  who  had 
a  protuberance  at  the  dorsal  region  of  the  vertebral  column,  the 
arch  of  the  aorta  and  the  commencement  of  the  descending  aorta 
much  more  dilated  than  in  an  ordinary  state.  This  appeared  to 
me  to  arise  from  the  difficulty  with  which  the  blood  passed 
through  the  vessel,  for  the  artery  itself  followed  the  inflexion  of 
the  vertebral  column. 

I  once  met  with  an  aneurism  of  the  ductus  arteriosus  in  an 
infant  at  birth  ;  the  following  is  an  account  of  this  case : 

CASE  LXXVIII. — Aneurism  of  the  ductus  arteriosus. — On  the 
25th  of  October,  1826,  there  was  brought  to  the  Hospice  des  Enfans 
Trouves  a  male  infant,  aged  two  days,  who,  on  the  following  day, 
was  placed  in  the  infirmary.  He  was  of  a  medium  size  and  constitu- 
tion ;  the  respiration  was  laborious ;  face  livid ;  cry  smothered  ;  tem- 
perature of  the  body  natural ;  pulse  small,  frequent,  and  easily  com- 
pressed. This  child  remained  two  days  in  the  same  state,  and  died 
on  the  third,  without  having  presented  any  other  symptom  than  those 
just  indicated.  On  examining  the  body,  the  mouth  and  oesophagus 
were  found  healthy  ;  the  intestinal  tube  the  seat  of  a  very  great  san- 
guineous congestion  ;  the  liver  was  gorged  with  blood,  as  were  also 
the  two  lungs. 

The  heart  was  larger  than  is  usual  for  an  infant  at  birth ;  the  two 


ON   THE    DISEASES    OP    INFANTS.  449 

lateral  cavities  were  nearly  equally  dilated,  and  were  filled  with  black 
clotted  blood ;  the  ductus  arteriosus  existed  in  the  form  of  a  large 
cherry-pit ;  its  transverse  diameter  was  about  three  lines  and  a  half, 
and  its  circumference  nine  ;  from  an  external  examination  it  appear- 
ed to  open  widely  into  the  aorta ;  this  size,  however,  existed  only 
exteriorly,  for  the  interior  of  the  tumor  was  filled  with  fibrous  clots, 
organized  and  disposed  in  layers,  as  is  seen  in  aneurismal  tumors  of 
adults,  leaving  in  the  centre  a  very  small  hole. 

The  other  organs  of  the  body  exhibited  nothing  peculiar. 

I  do  not  believe  that  the  symptoms  observed  in  this  child  were 
the  effect  of  this  aneurism  of  the  ductus  arteriosus  ;  it  can  be 
more  easily  accounted  for  by  the  state  of  the  lungs,  and  I  do  not 
think  that  any  external  sign  could  reveal  the  existence  of  this  dis- 
ease. I  have  only  recorded  it  as  a  case  of  rare  occurrence.  M. 
Baron  informs  that  he  has  also  met  with  a  similar  case  of  aneurism 
in  an  infant,  where  the  symptoms  also  presented  nothing  peculiar. 

Inflammation  of  the  heart  and  large  vessels  in  infants  at  the 
breast  is  very  rare,  and  doubtless  very  difficult  to  ascertain.  I 
am  not  in  possession  of  any  positive  data  on  this  pathological 
point ;  I  shall  confine  myself  here  to  some  observations  on  the 
color  of  these  organs. 

The  external  surface  of  the  heart  is  usually  of  a  deep  red  in 
young  infants,  and  its  extreme  paleness  ought  to  be  regarded 
as  an  abnormal  state.  The  internal  surface  is  also  of  a  red  color, 
more  or  less  deep,  and  sometimes  there  is  a  marked  difference  be- 
tween the  two  ventricles  ;  the  right  cavities  are  of  a  violet,  and 
they  have  been  seen  of  the  color  of  Campeachy  wood,  while 
the  left  cavities  preserve  their  ordinary  red  aspect.  In  these 
cases  the  venous  blood  predominates ;  the  larger  vessels  are 
gorged  with  it,  as  well  as  all  the  tissues  ;  putrefaction,  even  when 
much  advanced,  does  not  produce  the  same  effect ;  and  it  does 
not  show  itself  more  in  all  subjects  where  there  exists  a  consider- 
able venous  congestion.  This  difference  of  color,  which  I  have 
also  observed  in  adults,  arises  from  some  cause  with  which  I  am 
unacquainted ;  I  shall  therefore  confine  myself  to  pointing  out 
the  effects  of  it. 

The  vascular  system  of  a  young  child  is  remarkable  for  its 
habitual  sanguineous  turgescence ;  it  is  also  very  common,  in 
young  infants,  to  meet  with  engorgements,  ecchymoses,  and  san- 

57 


450  ON   THE    DISEASES    OF   INFANTS. 

guineous  effusions  in  different  parts,  but  particularly  in  the  most 
dependant,  and  in  those  where  there  is  much  cellular  tissue.  The 
vessels,  notwithstanding  their  fulness,  are  not  always  colored 
with  the  blood  contained  in  them ;  and  when  their  branches  are 
followed  into  organs,  the  tissue  of  which  is  impregnated  with  a 
large  quantity  of  blood,  they  are  often  seen  almost  white,  or  of  a 
slight  rose  color,  in  the  midst  of  the  tissue.  I  have  been  led  to 
this  remark  by  the  anatomical  researches  which  I  made  to  satisfy 
myself  whether  these  vessels  in  young  infants  partook  of  the 
coloring  of  the  organs  to  which  they  passed,  as  M.  Trousseau  has 
observed  was  the  case  in  a  number  of  animals  he  examined. 

§  11.     Pericarditis. 

If  inflammation  of  the  proper  tissue  of  the  heart  is  rare  or  dif- 
ficult to  prove  in  young  infants,  inflammation  of  the  pericardium 
is  more  common.  Perhaps  it  is  even  more  frequent  at  the  first 
period  of  hfe  than  at  any  other ;  in  nearly  seven  hundred  post 
mortem  examinations  which  I  made  at  the  Hospice  des  Enfans 
Trouves,  I  have  seen  seven  well-marked  cases  of  pericarditis. 

The  causes  of  this  disease  are  difficult  to  explain,  particularly 
if  we  compare  them  with  those  which  produce  it  in  adults.  It  is 
well  known  that  Pinel  has  pointed  out  among  the  causes  the 
immoderate  exercise  of  the  mental  powers,  and  in  support  of  this 
assertion  has  cited  the  history  and  death  of  Mirabeau,  whose 
youthful  hilarity  and  great  moral  activity  appear  to  have,  for  a 
long  time,  disposed  him  to  the  pericarditis,  which  caused  his 
death  ;*  but  nothing  of  this  kind  is  to  be  observed  in  the  vegeta- 
tive life  of  new-born  children,  who,  however,  die  of  this  disease. 
It  is  sufficient,  then,  that  the  functional  activity  of  the  heart  is 
increased,  and  the  irritability  of  the  organ  redoubled,  for  its  serous 
envelop  to  become  inflamed  and  give  rise  to  the  most  serious  ac- 
cidents. This  is  undoubtedly  the  cause  of  the  frequency  of  this 
disease  in  those  affected  with  aneurism,  and  in  nervous  females 
who  are  subject  to  palpitations. 

The  symptoms  of  pericarditis  in  young  infants  are  not  easily 
recognised,  because  they  may  be  confounded  with  those  of  pleu- 
risy, meningitis,  or  gelatinous  softening  of  the  brain. 

*  Nosographii  -philos.^  t.  ii.,  p.  44. 


ON   THE    DISEASES    OP    INFANTS.  451 

In  general,  children  affected  with  this  disease  appear  to  expe- 
rience violent  pain  ;  their  cry  is  painful ;  respiration  labored  and 
sometimes  suffocating ;  the  face  is  pinched ;  the  muscles  of  the 
face  appear  to  be  constantly  contracting.  1  have,  in  two  instan- 
ces, seen  spasmodic  movements  of  the  limbs.  Pericarditis  is 
usually  very  rapid  in  its  progress,  and  children  die  without  ex- 
hibiting symptoms  more  strongly  marked  than  those  just  described. 
It  is,  then,  almost  impossible  to  make  a  diagnosis  of  this  disease ; 
yet  we  may  make  a  remark  with  regard  to  the  subject  before  us : 
it  is,  that  when  there  exists  a  state  of  general  restlessness,  dis- 
tress, and  suffering,  in  young  infants,  there  is  almost  always  a 
gelatinous  softening  of  the  stomach,  pericarditis,  or  acute  pleuri- 
sy ;  and  our  judgment  must  be  directed  to  a  decision  between 
these  three  different  diseases,  when  we  see  these  symptoms  in  a 
young  infant.  The  pulse  does  not  exhibit  any  thing  worthy  of 
remark ;  it  is  the  same  with  regard  to  percussion  and  ausculta- 
tion ;  and  therefore  in  every  case  of  pericarditis  which  I  have 
seen,  it  has  not  been  possible  to  establish,  by  evident  signs,  a 
diagnosis  of  the  disease  ;  the  post  mortem  examination  alone  has 
demonstrated  its  existence. 

I  once  saw,  in  an  infant  two  days  old,  firm  adhesions  between 
the  layers  of  the  pericardium,  producing  the  belief  that  they 
were  the  product  of  a  former  pericarditis,  developed  during  the 
evolution  of  the  foetus.  In  six  other  cases  there  was  a  sero-albu- 
minous  effusion  in  the  pericardium,  white  flakes  adhering  to  the 
surface  of  the  heart,  and  very  slight  bands  between  the  two 
larger  layers  of  the  cardiac  envelop. 

The  pericardium  and  the  external  surface  of  the  heart  very 
often  present,  in  young  infants,  violet-colored  petechise  ;  a  sero- 
sanguineous  effusion,  or  even  an  effusion  of  pure  blood,  ordina- 
rily accompanied  this  petechial  eruption.  I  do  not  think  that 
this  lesion  ought  to  be  attributed  to  inflammation  ;  it  appears 
rather  to  be  the  effect  of  passive  congestion.  In  general  there  is 
almost  always  found  a  certain  quantity  of  serosity  in  the  pericar- 
dium of  young  infants. 

If  it  be  possible  to  detect  the  existence  of  pericarditis,  the 
treatment  of  it  should  be  the  same  as  that  of  pleurisy. 

The  thymus  gland  is  susceptible  of  being  affected  with  certain 
diseases  during  the  short  space  of  its  transient  existence.    I  have 


452  ON    THE    DISEASES    OP    INFANTS. 

never  been  able  to  observe  any  peculiar  symptoms  belonging  to 
these  affections ;  but  on  opening  the  bodies  of  children,  I  have 
seen  it  in  two  instances  much  tumefied,  very  red,  and  extremely 
friable.  I  considered  it  as  the  result  of  an  inflammation  which 
perhaps  might  have  led  to  its  suppuration  or  disorganization. 
M.  Yeron  reported,  in  a  memoir  read  by  him  to  the  Academie 
Royale  de  Medecine,  at  its  sitting  on  the  26th  of  April,  1826,  an 
instance  of  an  inflammation  of  this  gland,  with  the  formation  of 
pus  in  the  interior  of  this  organ. 

I  shall  here  finish  my  remarks  on  the  inflammatory  diseases 
of  the  respiratory  and  circulatory  apparatus  in  sucking  children. 
I  ought  perhaps  to  treat  of  emphysema  of  the  lungs,  asthma,  and 
nervous  aflections  of  the  respiratory  organs  generally ;  but  em- 
physema of  the  lungs,  although  common  in  young  infants,  does 
not  produce  any  peculiar  symptom ;  and  further,  nervous  affec- 
tions of  the  circulatory  apparatus  do  not  belong  exclusively  to 
the  diseases  of  infants  ;  the  history,  therefore,  of  these  affections 
should  be  referred  more  especially  to  works  of  general  pathology, 
or  to  treatises  particularly  devoted  to  the  diseases  of  the  thoracic 


CHAPTER  X. 

DISEASES    OP    THE    CEREBRO-SPINAL    APPARATUS. 

If  there  be  one  point  in  the  pathology  of  new-born  children 
which  can  demonstrate  the  utility  of  considering  together  the 
science  of  organization,  and  the  clinical  observation  of  diseases, 
it  is  the  history  of  the  diseases  of  the  encephalon.  We  shall  see, 
indeed,  what  important  modification  of  the  organic  condition  of 
the  brain  of  young  infants  is  caused  by  the  progress  and  nature 
of  their  cerebro-spinal  diseases.  Let  us  commence  by  taking  a 
rapid  view  of  the  development  of  the  spinal  marrow  and  brain. 

A  great  number  of  authors,  from  the  time  of  Galen,  have  con- 
sidered the  medulla  spinalis  as  an  appendage  to  the  encephalon; 
but  Gall  has  revived  the  contrary  opinion,  which  had  been  sup- 
ported by  Plato.  Praxagoras,  and  Philotenus  ;  and  the  immortal 


ON   THE    DISEASES    OP    INFANTS.  453 

works  of  Tiedemann  confirm  this  idea  of  Dr.  Gall.  It  is  now- 
demonstrated  that  the  medulla  spinalis  is  developed  before  the 
cerebrum,  which  is  the  expansion  of  the  spinal  marrow,  and 
which  originally  is  very  small  compared  with  the  spinal  prolon- 
gation. 

About  the  third  or  fourth  week,  there  is  perceived  in  the  cavi- 
ties of  the  head  and  spine  a  grayish  fluid;  from  the  fourth  to 
the  fifth  week,  the  medulla  oblongata  is  distinctly  seen,  bending 
forward  at  the  place  of  the  union  of  the  head  with  the  spine  ; 
at  this  time,  the  spinal  marrow  is  formed  of  two  white  threads, 
which  gradually  inclining  backward,  form  a  kind  of  longitudinal 
groove,  so  that  at  seven  weeks  the  medulla  spinalis  appears  cleft 
in  its  whole  extent ;  the  rudiments  of  the  cerebellum  are  then 
for  the  first  time  to  be  seen,  and  the  cervical  swelling  coinciding 
with  the  appearance  of  the  superior  extremities.  At  the  begin- 
ning of  the  third  month,  the  medulla  spinalis  is  still  open  at  its 
upper  half,  and  exhibits  nothing  more  in  the  remainder  of  its 
extent  than  a  longitudinal  raphe,  which  is  the  mark  of  reunion 
of  the  two  primitive  cords  ;  the  tubercula  quadrigemina  are  large, 
the  thalami  nervorum  opticorum  perfect,  and  the  enlargement  of 
the  medulla  very  evident ;  at  the  twelfth  week,  the  spinal  marrow 
extends  only  halfway  down  the  sacrum,  the  tubercula  quadrige- 
mina are  united,  and  the  medullary  eminences  are  easily  distin- 
guished, together  with  the  corpora  striata.  There  exists  an  inter- 
nal canal  produced  by  the  turning  over  of  the  borders  of  the 
medulla,  which  communicates  with  the  fourth  ventricle.  This 
canal  is  obliterated  by  the  formation  of  the  cineritious  substance, 
which  is  secreted  in  the  interior,  so  that  at  the  sixth  month  it  is 
no  longer  found  in  well-formed  embryos.  At  the  fifth  month,  the 
corpora  pyramidal ia,  pons  varolii,  and  corpora  striata,  are  very 
large,  and  the  human  embryo  exhibits  a  caudal  prolongation ; 
it  quickly  diminishes  as  the  development  and  elongation  of  the 
Tertebral  column,  according  to  Tiedemann,  rapidly  takes  place, 
whilst  the  medulla  spinalis  continues  fixed  in  its  place.  At  the 
eighth  month,  the  spinal  cord  extends  only  to  the  fourth  lumbar 
vertebra ;  it  terminates  in  small  nervous  filaments,  constituting 
the  Cauda  equina.  Finally,  at  birth  the  medulla  spinalis  and 
medulla  oblongata,  which  is  an  appendage  to  it,  exhibit  their 
constituent  parts  very  distinctly  formed. 


454  ON    THE    DISEASES    OP   INFANTS. 

In  fact,  the  corpora  striata  are  observed  forming  a  well-marked 
lateral  projection,  the  cords  of  which  penetrate  into  the  thalami 
optici  from  the  crura  cerebri ;  and  the  pons  variolii  is  found 
composed  of  fibres  from  the  lateral  parts  of  the  cerebellum,  and 
of  those  coming  from  the  opposite  hemisphere,  and  which  are 
disposed  in  layers  alternating  with  fibres  directed  obliquely  from 
the  corpora  pyramid  alia  to  the  thalami  nervorum  opticorum. 

While  the  medulla  spinalis  is  undergoing  these  different  evo- 
lutions, the  cerebrum  and  cerebellum  gradually  acquire  their 
proper  form  and  organization.  The  cerebellum,  which  at  first 
consists  only  of  two  laminae  turned  towards  each  other,  is  pro- 
duced by  the  enlargement  of  these  two  laminae,  which  arise  and 
are  united  above  the  fourth  ventricle,  and  by  degrees  are  ar- 
ranged in  branches  and  twigs,  which  are  seen  in  the  substance 
of  this  organ.  From  the  corpora  pyramidalia  arise  the  thalami 
nervorum  opticorum  and  the  corpora  striata,  which  terminate  on 
the  outside  by  a  lamina,  which  is  observed  to  be  reflected  from 
before  backward,  and  from  without  inward,  to  form  the  cerebral 
hemispheres. 

These  membranous  hemispheres  are  so  short  at  the  second 
month,  that  they  scarcely  cover  the  corpora  striata;  but  in  pro- 
portion-as they  increase  in  size  they  successively  cover  the  tha- 
lami nervorum  opticorum,  the  tubercula  quadrigemina,  and 
lastly  the  cerebellum.  It  is  their  inflexion  on  themselves  which 
gives  rise  to  the  lateral  ventricles.  From  this  short  view  of  the 
formation  of  the  medulla  spinalis  and  encephalon,  we  see  that 
the  cerebral  mass  is  produced  by  the  spinal  marrow,  of  which, 
as  Reil  has  observed,  it  is  an  efflorescence.* 

If  this  be  true,  the  medulla  spinalis  and  medulla  oblongata 
would  at  the  period  of  birth  exhibit  an  almost  perfect  develop- 
ment, and  in  the  fulfilment  of  their  important  functions,  whilst 
the  cerebral  lobes,  less' useful  at  this  period  of  life,  would  be  less 
advanced  in  organization ;  this  is  indeed  what  really  exists.  , 
M.  Tiedemann  has  remarked,  with  much  reason,  that  in  infants 
of  the  age  of  six,  seven,  eight,  and  nine  months,  the  brain  ex- 

♦  For  further  details  on  the  formation  of  the  encephalon,  consult  Tiedemann,  Ana- 
tomic du  cevreau  contenant  Vhistoire  de  son  developement  dans  le  fcctus;  translated 
by  A.  G.  L.  Jourdan.  Paris,  1823 — Ollivier,  Traite  de  la  moelle  epiniere  et  de  ses 
maladies.     Second  edition,     Paris,  1827. — Series,  Anatomie  comparee  du  cerveau. 


ON   THE    DISEASES   OF    INFANTS.  455 

hibits  a  homogeneons  substance  of  a  light  red,  in  which  it  is  diffi- 
cult to  distinguish  the  c;neritious  from  the  medullary  substance. 
From  numerous  dissections,  I  am  satisfied  of  the  correctness  of 
the  assertion  of  M.  Tiedemann.  The  following  are  the  results 
of  my  researches  on  this  subject  :* 

In  a  child  just  born,  the  medulla  spinalis  is  white,  its  cineri- 
tious  centre  is  not  altogether  of  the  same  color  as  in  the  adult, 
but  is  more  of  a  rosy  hue,  and  softer.  It  is  easy  to  uhrol  the 
two  lateral  cords  of  which  it  is  formed.  Its  consistence  is  suffi- 
ciently firm  to  allow  of  its  being  cut  smoothly. 

The  brain  of  a  new-born  child  only  resembles  that  of  an  adult 
in  its  general  form  ;  it  differs  entirely  in  its  consistence  and  as- 
pect. Its  consistence  is  like  that  of  paste,  and  will  allow  of  being 
cut  tolerably  smooth  ;  but  it  soon  softens  when  in  contact  with 
air ;  its  color  is  white,  and  there  exists  as  yet  no  well-marked 
line  of  demarcation  between  the  cineritious  and  medullary 
substance,  so  that  in  cutting  the  hemisphere  horizontally,  the 
centrum  ovale  does  not  appear  as  in  adults.  Yet  the  seat  of  the 
cortical  substance  may  be  discovered  by  the  presence  of  a  line 
less  colored  than  the  central  substance,  and  which  winds  over 
the  superficies  of  the  brain  throughout  its  circumvolutions.  The 
white  substance  of  the  brain  is  generally  very  much  injected, 
or  has  a  large  number  of  vessels  passing  through  it.  "In  every 
part  where  we  have  ^und  the  gray  substance  accumulated  in 
considerable  masses  in  the  adult,"  observes  M.  Tiedemann,t  "as 
in  the  cerebral  peduncles,  corpora  striata,  thalami  nervorum  op- 
ticorum,  (fee,  I  have  observed  only  that  the  vessels  were  larger 
and  more  numerous  than  in  those  which  are  composed  of  me- 
dullary substance,  after  the  period  of  birth.  The  parts  which 
correspond  to  the  corpora  striata  in  the  brain  of  a  foetus  are  com- 
posed of  a  white  homogeneous  substance,  with  a  reddish  tint,  and 
penetrated  by  a  number  of  large  vessels.  The  cerebellum  also 
does  not  present  between  these  two  substances  as  marked  a 
difference  as  at  a  more  advanced  age ;  but  yet  they  are  more 
easily  distinguished,  and  appear  much  sooner  than  in  the  brain." 

*  These  details  are  inserted  by  Professor  Orfila,  in  the  1st  vol.  of  his  Legons  de 
medicine  legale.     Paris,  1828. 

i  Anatomie  du  cerveau  contetiant  Vhistoire  de  son  developement  dans  le  fcetus^ 
etc. ;  translated  by  A,  G.  L.  Jourdan.    Paris,  1824,  p.  120. 


456  ON   THE    DISEASES   OP    INFANTS. 

As  the  child  advances  in  age,  the  various  constituent  parts  of 
the  brain  assume  an  aspect,  form,  and  anatomical  organization 
which  they  are  to  have  during  the  remainder  of  life.  From  the 
ninth  month  to  one  year,  the  gray  substance  acquires  a  degree 
of  vital  energy,  which  doubtless  results  from  the  modification 
occurring  in  its  texture  ;  it  first  appears  of  a  rose-color,  then  red, 
brown,  and  lastly,  of  a  reddish  gray.  It  is  to  be  observed  that 
the  parts  of  the  cerebral  mass  which  are  the  nearest  to  the  medulla 
oblongata  are  also  more  advanced  in  their  organization  than  those 
more  remote — a  natural  consequence  of  the  mode  of  organization 
of  the  cerebro-spinal  apparatus,  the  development  of  which  passes 
progressively  from  the  medulla  spinalis  towards  the  encephalon. 

It  appears,  therefore,  that,  from  birth  to  the  age  of  one  year, 
the  brain  of  a  child  is  in  a  true  state  of  transition,  and  that  this 
organ,  scarcely  perceptible  in  the  beginning,  reaches  its  proper 
organization  about  the  ninth  or  twelfth  month.  Is  it  not  owing 
to  this  modification  occurring  in  the  brain  of  a  child  that  the 
frequency  of  cerebral  affections  at  this  age  is  to  be  ascribed  ?  It 
happens  also  that  at  this  period  the  teeth  first  make  their  ap- 
pearance, and  it  has  long  been  believed  that  convulsions  and 
other  cerebral  diseases  are  to  be  attributed  to  this  cause.  This 
opinion,  found  in  the  writings  of  Hippocrates,  doubtless  derives 
its  principal  support  from  the  respect  and  authority  which  the 
name  of  the  father  of  medicine  usually  inspires.  But  whatever 
Hippocrates  may  have  said  on  this  subject,  it  is  evident  that  the 
true  cause  of  the  frequency  of  cerebral  affections  in  infants  at  the 
period  of  dentition,  is  in  the  brain.  Dentition  can  be  only  one 
of  the  accidental  causes  of  cerebral  diseases  ;  the  predisposing 
cause  exists  in  the  organic  modifications  supervening  in  the  en- 
cephalon, and  it  is  to  this  part  that  we  ought  to  direct  our  treat- 
ment. Not  only  has  the  brain  undergone,  during  the  first  year, 
the  organic  modifications  just  pointed  out,  but  the  exercise  of  its 
functions  has  also  increased  ;  it  has  gradually  acquired  its  con- 
trol over  the  other  organs,  and  it  has  become  fit  to  receive  from 
them  the  sympathetic  indications  with  which  it  was  before  unaf- 
fected ;  it  is  the  centre  and  regulator  of  the  sensations,  and  this 
influence  is  felt  even  in  disease ;  we  frequently  see,  during  the 
first  periods  of  life,  great  alterations  in  the  organs,  unaccompa- 
nied by  any  febrile  reaction,  any  general  symptom,  or  any  mor- 


ON   THE    DISEASES    OF    INFANTS.  457 

bid  sympathy ;  bat  at  the  age  of  which  we  are  now  speaking, 
every  thing  assumes  a  new  aspect ;  fever,  which  is  scarcely  ever 
seen  in  new-born  children,  here  makes  its  appearance  on  the 
slightest  cause ;  hence  the  restlessness,  cries,  spasms,  nervous 
mobility,  so  common,  so  easily  excited,  and  at  the  same  time  so 
transient,  in  children  who  have  passed  the  period  of  infancy. 
These  considerations  will  prove  to  us  the  difficulty  of  studyino- 
the  diseases  of  early  infancy ;  the  cause  is  evidently  in  the  or- 
ganic imperfection  of  the  encephalon,  which  cannot  reveal  to  us 
the  signs  and  external  symptoms  of  these  diseases. 

Whilst  the  medulla  spinalis  is  undergoing  its  organization,  the 
vertebral  column  has  also  passed  through  its  periods  of  forma- 
tion in  nearly  the  same  manner.  The  spine,  according  to 
Meckel,  is,  in  the  beginning,  in  the  form  of  a  groove,  continuing 
open  posteriorly  for  some  time,  and  which  closes  by  the  union  of 
the  lamina  of  the  spinous  processes.  The  cranium  is,  at  first, 
entirely  membranous  ;  its  ossification  commences  early  about 
the  foramen  magnum  ;  the  different  bones  composing  it  exhibit 
in  the  centre  a  primitive  point  of  ossification,  extending  by  radia- 
tion towards  the  circumference  of  the  bone,  the  borders  and  an- 
gles of  which  are  still  separated  at  the  period  of  birth,  by  cartila- 
ginous or  membranous  intervals,  which  permit  the  different 
parts  of  the  cranial  cavity  to  move  over  each  other  with  great 
facility. 

The  membranes  of  the  spinal  marrow  and  brain  are  formed 
very  early,  and  present  their  peculiar  disposition  and  form,  so 
that  at  birth  they  possess  all  their  vital  and  organic  properties  ; 
their  diseases,  therefore,  are  similar  to  those  of  the  meninges  in 
adults,  giving  rise  to  nearly  the  same  symptoms. 

The  arrangement  of  the  vascular  system  of  the  brain  and  spi- 
nal marrow  deserves  the  attention  of  physicians,  for  the  disturb- 
ances which  supervene  in  the  cerebro-spinal  circulation  may 
arise  from  the  disposition  of  these  vessels.  There  are  the  large 
meningo-spinal  veins  which  pass  up  through  the  lateral  parts  of 
the  spine,  and  also  a  network  of  veins,  described  by  M.  Breschet, 
between  the  dura  mater  and  the  posterior  surface  of  the  vertebrae. 
Besides  these,  there  are  veins  of  which  M.  Dupuytren  has  given 
an  account  under  the  name  of  Mediilli  spinales,  and  M..  Chaus- 
sier  under  that  of  Medianes  rachidiennes^  particularly  destined 

58 


458  ON   THE    DISEASES   OF    INFANTS. 

to  the  spinal  marrow.  There  is  also  behind  the  dura  mater 
a  thick  layer  of  cellular  tissue,  which,  in  young  infants,  is  infil- 
trated with  a  yellow  serosity,  the  consistence  of  which  is  some- 
times gelatinous,  and  must  not  then  be  considered  as  a  morbid 
production.  The  network  of  spinal  veins  is  almost  always  en- 
gorged with  blood,  arising,  without  doubt,  from  the  1  enter  with 
which  the  venous  circulation  of  the  spine  is  affected  at  this  pe- 
riod of  life ;  the  arteries  present  nothing  peculiar. 

M.  Magendie  has  recently  observed  that  there  exists  between 
the  pia  mater  and  the  tunica  arachnoidea,  which  is  reflected  on 
itself,  a  space  of  greater  or  less  size,  which,  as  M.  Ollivier  remark- 
ed, is  interrupted  at  intervals  by  small  thin  ligaments,  and  where 
there  is  constantly  during  life  a  serous  fluid,  communicating,  as 
M.  Magendie  observes,  with  the  fluids  of  the  cerebral  ventricles  ;* 
the  pia  mater,  Avhich  is  essentially  vascular,  while  the  tunica 
arachnoidea  is  without  vessels,  is  less  adherent  to  the  surface  of 
the  brain  in  children  than  in  adults;  it  has  hkewise  been  re- 
marked that  the  pia  mater  of  the  medulla  is  more  cellular  and 
solid  than  that  of  the  brain,  and  Bichat  has  observed  that  this 
membrane  becomes  thicker  at  its  inferior  part ;  in  order,  there- 
fore, to  satisfy  ourselves  of  the  state  of  softness  or  firmness  of  the 
medulla  spinalis,  we  must  always  remove  from  it  the  pia  mater, 
which  can  easily  be  done. 

The  brain  and  spinal  marrow  are,  during  life,  in  a  state  of 
continual  movement,  elevation,  and  depression  ;  the  motion  of 
the  spinal  marrow  was  a  long  time  unknown  ;  the  demonstra- 
tion of  it  is  due  to  M.  Ollivier,  and  who  has,  I  think,  very  satis- 
factorily explained  its  mechanism.  There  are,  says  he,  three 
very  evident  causes  which  produce  the  motion  observed  through- 
out the  whole  length  of  the  spine ;  first,  the  shock  of  the  part 
from  the  action  of  respiration  on  this  organ,  next  the  dilatation 
of  the  vessels  when  there  is  an  afflux  of  blood,  and  lastly,  the 
motion  of  the  spinal  fluid  by  each  respiration.! 

The  primary  anatomical  and  physiological  data  being  estab- 
lished, let  us  pass  to  the  study  of  the  congenital  malformations  of 
the  cerebro-spinal  apparatus.     My  object  is  not  to  give  a  com- 

*  Journal  de  Physiologic  Exper.  et  Path.,  tome  v. 
t  Olliv.  loc.  cit.,  page  43. 


ON   THE    DISEASES    OP    INFANTS.  459 

plete  history  of  them,  but  to  consider  them  in  their  relation  to  the 
symptoms  of  the  diseases  of  infants. 

Congenital  malformations. — The  complete  absence  of  the 
medulla  is  called  amyelia ;  it  would  appear  that  its  absence  is 
always  coincident  with  that  of  the  brain.  Morgagni  has  given 
several  instances  of  the  simultaneous  absence  of  the  brain  and 
spinal  marrow.  M.  OUivier  has  reported,  in  the  scientific  jour- 
nals, nearly  all  the  facts  upon  this  subject,  and  it  has  been  re- 
marked that,  in  nearly  all  the  individuals  affected  with  this  de- 
formity, spina  bifida  was  found  more  or  less  complete.  Yet  it 
must  not  be  concluded  from  this  that  the  absence  of  the  parts 
contained  will  always  produce  that  of  the  containing  parts,  as 
MM.  Serres  and  Geoffroy  Saint-Hilaire  have  thought.  Still  the 
coincidence  is  not  uncommon.  Every  thing  leads  to  the  belief 
that  the  absence  of  the  medulla  is  the  result  of  disease  rather 
than  the  effect  of  an  arrest  of  development.  I  shall  not  consider 
the  reasons  with  which  Beclard,  MM.  Meckel,*  Ollivier,  Duges, 
and  a  number  of  others,  have  adduced  in  support  of  this  opinion. 
I  will  only  observe  that  there  are  many  cases  in  confirmation 
of  it. 

The  medulla  spinalis  may  exhibit  a  deformity  at  its  upper  ex- 
tremity ;  in  the  case  of  anencephalia,  the  pons  varolii  exists,  or 
may  present  nothing  more  than  the  rudiments ;  sometimes  the 
spinal  cord  exhibits  a  trace,  more  or  less  deep,  of  its  division  into 
two  lateral  portions,  or  it  is  suddenly  obliterated  near  the  fourth 
ventricle.  Children  affected  with  this  deformity  do  not  die  im- 
mediately after  birth,  for  the  heart  and  lungs,  which  receive 
their  nervous  influence  from  the  upper  portion  of  the  medulla, 
may  perform  their  functions  for  some  time  in  a  manner  that  will 
preserve  life  for  many  days.  Indeed  such  children  have  been 
seen  to  respire,  cry,  suck,  and  swallow. 

The  division  of  the  medulla  spinalis  into  two  lateral  cords,  to 
a  greater  or  less  extent,  which  Zacchias,  Manget,  and  Hall  have 
pointed  out,  and  which  I  also  have  given  an  instance  in  the  work 
of  M.  OUivierjt  may  exist  with  complete  spina-bifida,  although 
the  skin  may  be  perfect  at  the  place  of  the  separation  of  the  ver- 
tebra ;  this  malformation  will  not  allow  of  the  establishment  of 

•  Manual  of  General,  Descriptive,  and  Pathological  Anatomy.     Philadelphia,  1832. 
t  Loc.  cit,  t.  i.,  p.  167. 


460  ON  THE    DISEASES    OP   INFANTS. 

independent  life,  and  children  thus  affected  die  immediately  after 
birth,  or  give  no  sign  of  life  ;  another  malformation  consists  in 
the  doubling  of  the  medullary  portion,  and  is  particularly  met 
with  in  foetuses  that  are  double.  Lastly,  in  the  centre  of  the 
medulla  spinalis  may  be  a  canal,  the  effect  of  a  mechanical  dis- 
tension which  this  organ  may  experience  from  the  serosity  accu- 
mulating in  the  centre  of  the  cerebral  cavities,  in  cases  of  hydro- 
cephalus or  hydrorachis. 

Hydrorachis  consists  in  one  or  more  tumors  situated  in  the 
vertebral  column,  over  an  opening  between  the  spinous  process- 
es, resulting  from  an  accumulation  of  serosity  contained  in  a 
sac  formed  by  the  skin  and  the  meninges. 

In  hydrorachis,  the  tumor  may  be  situated  at  the  superior, 
middle,  or  inferior  part  of  the  vertebral  column  ;  its  form  may  be 
of  that  of  a  chestnut  (marronee),  oblong,  irregularly  round,  or 
multi-lobed  ;  its  consistence  that  of  a  cyst,  enclosing  a  fluid  which 
disappears  more  or  less  on  slight  pressure,  flowing,  no  doubt,  to- 
wards the  brain.  This  pressure  is  generally  painful.  Where- 
ever  it  may  be  seated,  it  exhibits  three  stages  or  varieties  of  as- 
pect, of  which  the  distinction  is  really  of  practical  utility.  1st, 
The  skin  covering  it  is  healthy,  like  that  of  the  other  parts  of 
the  body  ;  the  seat  of  the  disease,  the  fluctuation,  and  the  sensa- 
tion of  an  opening  between  the  vertebras,  are  the  only  signs  by 
which  the  existence  of  hydrorachis  can  then  be  ascertained. 
This  variety  evidently  demonstrates  that  the  skin  concurs  in  the 
formation  of  the  walls  of  the  tumor.  This  form  of  the  disease 
is  less  dangerous  than  the  others,  and  may  continue  a  long  time 
without  any  serious  consequences.  2dly,  The  skin  is  sometimes 
very  thin  and  transparent,  and  crossed  by  purple  lines  ;  in  some 
cases  there  oozes  out  a  sero-purulent  or  sanguineous  fluid,  which 
indicates  the  approaching  rupture  of  the  tumor.  3dly,  The 
tumor  may  be  open,  presenting,  at  the  bottom,  a  very  fine  perfo- 
rated membrane,  and  allowing  of  the  escape  of  a  quantity  of  va- 
riable fluid.  There  is  a  red  rugous  ring  surrounding  this  rup- 
ture, formed  by  the  skin  and  subcutaneous  tissue.  This  ring  is 
harder  where  it  is  near  the  edges  of  the  vertebral  bifurcation. 

The  two  last  varieties  are  much  more  common  than  the  first ; 
and  as  infants  are  almost  always  born  with  spina-bifida  in  a  state 
of  ulceration,  some  authors  have  thought  that  the  skin  formed  no 


ON   THE    DISEASES    OP    INFANTS.  451 

part  of  the  walls  of  the  sac.  In  seven  cases  of  spina-bifida,  ob- 
served in  the  wards  of  the  hospital,  in  1826, 1  saw  two  where  the 
tumor  was  covered  by  perfect  skin  ;  one  of  these  children  lived 
two  months,  and  died  from  pneumonia.  In  the  other,  the  tumor 
was  ulcerated,  and  by  degrees  assumed  the  apearance  which  it 
usually  has. 

The  opening  of  the  tumor  accompanying  hydrorachis,  is  al- 
ways a  most  unfortunate  circumstance,  for  inflammation  of  the 
meninges  quickly  follows,  and  all  its  train  of  bad  consequences, 
even  death  itself  If  a  child,  therefore,  be  born  with  an  ulcera- 
ted tumor,  but  incompletely  perforated,  it  ought  not  to  be  opened  in 
order  to  effect  a  discharge  of  the  fluid.  Morgagni  has  reported  a 
fatal  instance  from  this  operation,  which  an  ignorant  physician 
performed,  in  opposition  to  his  advice ;  scarcely  was  the  tumor 
opened  when  the  child  became  prostrated,  and  on  the  third  day 
died.  "  Non  vixit  autem  ad  totum  terthtm  ah  inciso  tiimore 
diem.  Ex  quo  enijn  hie  incisus  est,  nunqaam  jlere  et  clamare 
destitit,  qui  anted  hilaris  esset  ac  ridibundus  et  mamman  fere 
arevsari  cujas  semper  appetens  fuisset.''* 

In  seven  children  affected  with  hydrorachis  and  spina-bifida, 
who  died,  there  were  five  who  exhibited  spinal  meningitis.  Those 
in  whom  the  tumor  was  not  perforated,  remained  for  some  time 
without  exhibiting  the  slightest  symptom  ;  but  immediately  after 
the  destruction  of  the  walls  of  the  cyst,  the  fluid  flowed  out  and 
convulsions  followed,  which  continued  until  death  ;  where  there 
has  existed  a  perforation  of  the  tumor,  the  convulsions  have  com- 
menced at  birth,  and  continued  until  the  death  of  the  child ;  it 
is  evident,  then,  that  death  in  this  case  was  caused  by  spinal 
meningitis,  which  soon  extended  even  to  the  brain. 

In  dissecting  the  vertebral  column  and  the  tumor  of  the  chil- 
dren affected  with  spina-bifida,  [  found  in  five  of  them  an  abun- 
dant eff'usion  of  serosity  in  the  scull  and  spine,  so  that  it  is  pro- 
bable that  the  separation  of  the  vertebrae,  and  the  tumor  follow- 
ing it,  are  the  ordinary  results  of  this  accumulation  of  serosity, 
or  of  this  encephalo-spinal  dropsy.  In  two  children  in  whom  the 
tumor,  which  was  small  in  size,  was  situated  in  the  sacral  region, 
and  which  was  covered  with  unbroken  skin,  the  brain  was  per- 
fectly healthy,  the  ventricles  had  not  been  distended,  and  there 

*  De  sed,  et  caus,  morborum,  lib.  1,  epist.  xcii.,  p.  193. 


462  ON   THE    DISEASES    OP    INFANTS. 

existed  no  serosity  except  in  the  spine.  The  medulla  spinalis 
was  perfectly  healthy.  Does  not  this  integrity  of  the  brain, 
which  coexisted  with  the  slightly  advanced  stage  of  the  tumor, 
prove  that  the  disease  commences  sometimes  in  the  spine  ?  I 
have  investigated  with  great  care  the  seat  of  this  serosity,  and  it 
appeared  to  me  to  exist  in  the  cavity  of  the  tunica  arachnoidea.  In 
one  instance,  it  was  between  the  tunica  arachnoidea  and  the  pia 
mater.  The  seat  of  this  dropsy  will  therefore  be  different  from 
that  of  the  cerebro-spinal  fluid  of  M.  Magendie ;  and  would  not 
this  circumstance  lead  to  the  belief  that  there  exists  a  serous 
fluid,  not  only  between  the  arachnoid  membrane  and  the  pia 
mater,  but  also  in  the  arachnoid  cavity  itself?  I  did  not  find 
this  fluid  thick,  turbid  and  floculent,  except  in  the  five  cases  where 
symptoms  of  meningitis  existed.  It  was  limpid  and  without 
floculi  in  two  others,  where  death  occurred  from  another  cause. 

I  have  not  always  found  a  perfect  communication  between  the 
spinal  and  cranial  fluid.  The  following  case  exhibits,  in  this 
respect,  a  very  peculiar  disposition. 

CASE  LXXIX. — Alexandrine  Depuis,  aged  two  days,  entered 
the  infirmary  on  the  7th  of  May ;  she  was  small  and  very  feeble. 
She  had,  at  the  lower  part  of  the  back,  an  elongated  tumor,  an  inch 
and  a  half  long  and  an  inch  wide,  the  walls  of  which,  without  being 
open,  were  purple  and  very  thin  ;  she  was  not  affected  with  convul- 
sions *,  the  limbs  were  (Edematous  ;  and  the  cry,  at  first  strong,  be- 
came by  degrees  husky  and  stifled.  This  child  died  on  the  8th  of 
May.  On  a  post  mortem  examination,  the  oesophagus  was  found 
ecchymosed  ;  the  stomach  and  intestinal  tube  slightly  injected  ;  the 
liver  healthy  ;  the  gall-bladder  empty  ;  the  left  lung  engorged  ;  and 
at  the  commencement  of  hepatization,  the  heart  gorged  with  blood ; 
the  ductus  arteriosus  widely  open.  Around  the  spinal  tumor  there 
existed  some  blood  effused  in  the  cellular  tissue.  The  separation  of 
the  vertebrae  existed  at  the  lumbar  region  ;  the  fluid  contained  in  the 
tumor  was  bloody  ;  it  was  easily  made  to  flow  through  the  whole 
length  of  the  spinal  marrow,  and  it  evidently  flowed  between  the 
tunica  arachnoidea  and  pia  mater.  The  lateral  ventricles  contained 
fluid  which,  instead  of  being  red,  was,  on  the  contrary,  of  a  trans- 
parent citron  color.  This  fluid  penetrated  into  the  middle  ventri- 
cle, and  the  aqueduct  of  Sylvius,  a  little  dilated,  permitted  it  to  de- 
scend into  the  fourth  ventricle,  beneath  which  was  a  small  red  pouch, 


ON   THE    DISEASES    OP    INFANTS.  463 

thin  and  flexible,  about  the  size  of  a  small  hazelnut.  It  formed  a 
cul-de-sac,  which  interrupted  all  communication  between  the  brain 
and  spine ;  when  it  was  pierced,  the  fluid  flowed  out,  and  it  im- 
mediately collapsed. 

This  case  exhibits  to  us  a  double  peculiarity ;  the  seat  of  the 
effused  fluid,  which  was  found  at  the  place  of  that  described  by 
M.  Maorendie,  and  the  evident  interception  between  the  brain  and 
the  spine.  I  found,  in  another  child  who  died  of  hydrorachis, 
the  fluid  efl'used  throughout  the  spine  of  a  yellow  color.,  and 
having  left  a  deposit  of  the  same  color  on  the  surface  of  the 
meninges,  whilst  the  serosity  of  the  brain  was  as  clear  as  it  usu- 
ally is.  * 

Although  these  facts  appear  to  be  contradictory,  yet  we  can  as- 
certain from  them  one  consequence,  that  the  fluid  of  cephalo-spinal 
dropsy  is  sometimes  effused  between  the  tunica  arachnoidea  and 
the  pia  mater,  and  sometimes  between  the  two  folds  of  the  tunica 
arachnoidea  ;  it  is  even  probable  that  the  source  of  the  secretion 
is  in  the  canal  described  by  M.  Masrendie,  and  that  it  is  intro- 
duced either  by  ruptures  of  the  arachnoid  membrane,  or  by  exuda- 
tion on  the  outside  of  the  canal,  which  had  become  too  narrow  to 
contain  it.  Such,  also,  is  the  opinion  of  M.  Ollivier.  The  com- 
munication of  this  canal  with  the  brain  appears  contradicted  by 
the  fact  which  I  have  just  stated  ;  yet,  as  it  is  the  only  one,  so 
far  as  I  know,  which  has  yet  been  published,  I  regard  it  as  a 
simple  exception.  Besides,  it  may  be  observed  that  the  large 
and  free  communication  existing  in  the  case  of  spina-bifida,  be- 
tween the  brain  and  spine,  is  always  the  effect  of  the  progress 
and  of  the  abundance  of  cerebro-spinal  effusion. 

The  medulla  spinalis  usually  remains  healthy  in  the  midst  of 
this  effused  fluid ;  sometimes,  however,  it  is  found  soft,  like  the 
walls  of  the  cerebral  ventricles  in  hydrocephalus.  It  may  at  the 
same  time  present  some  of  the  malformations  which  we  have 
pointed  out. 

There  are  generally  no  symptoms,  when  tlie  tumor  has  no 
communication  with  the  air,  and  when  the  fluid  does  not  com- 
press the  brain  or  spinal  marrow  so  as  to  interfere  with  the  ex- 
ercise of  their  functions.  Individuals  with  this  disease  have 
lived  to  quite  an  advanced  age  without  experiencing  any  unto- 


464  ON    THE    DISEASES    OF    INFANTS. 

ward  consequences ;  but  when  the  tumor  is  open,  spinal  menin- 
gitis, which  soon  supervenes,  gives  rise  to  all  the  symptoms 
which  it  usually  produces. 

Gentle  and  gradual  compression  of  the  tumor  is  the  only 
treatment  that  can  be  adopted ;  for  experience  has  not  as  yet 
justified  either  the  practice  of  opening  the  tumor  at  several  in- 
tervals with  a  fine  needle,  nor  the  method  of  passing  a  seton 
through  it:  for  inflammation  of  the  meninges  almost  always 
soon  follows  such  a  practice. 

Among  the  congenital  diseases  of  the  medulla  spinalis,  may 
be  mentioned  an  icterous  afiection  of  this  part,  and  which  M. 
Lobstein  has  described  recently  under  the  name  of  kyrronosis, 
and  of  which  he  has  seen  two  instances  in  embryos  of  five 
months.*  This  author  is  of  opinion  that  it  is  a  disease  peculiar 
to  the  first  period  of  intra-uterine  life ;  but  I  shall  give  several 
instances  of  a  yellow  coloring  of  the  brain  and  spinal  marrow, 
when  speaking  of  icterus,  which  appear  to  me  to  have  a  great 
analogy  to  the  kyrronosis  of  M.  Lobstein.  The  disease  may, 
therefore,  be  observed  at  other  periods  than  those  indicated  by 
the  learned  anatomist  of  Strasburg. 

Congenital  malformations  of  the  brain  and  cranium  are  of 
frequent  occurrence.  I  do  not  intend  here  to  give  their  history, 
causes,  mode  of  formation,  and  nomenclature,  but  only  to  con- 
sider them  hastily  in  their  relation  to  the  study  of  the  symptoms 
belonging  to  the  diseases  of  young  infants. 

Acephalia,  which  consists  in  the  absence  of  the  brain  and  even 
of  the  medulla  oblongata,  is  seen  only  when  the  head,  face,  and 
upper  part  of  the  neck  are  wanting  at  the  same  time  ;  in  such 
a  case  life  cannot  be  established,  and  the  foetus  had  only  existed 
by  its  communication  with  the  circulatory  apparatus  of  its  mo- 
ther, dies  as  soon  as  this  communication  is  broken  oif.  The 
respiratory  and  circulatory  apparatus  are  at  the  same  time  want- 
ing, or  are  incomplete. 

Anencephalia  also  deserves  our  attention.  It  consists  in  the 
absence  of  one  part  of  the  brain,  with  or  without  the  absence  of  the 
cranial  cavity.  It  is  so  common  to  meet  with  a  deformity  of  the 
cranium,  with  a  deformed  brain,  that  the  most  celebrated  anato- 

♦  Repertoire  cP anatomic  general,  1st  vol.    Paris,  1826. 


ON    THE    DISEASES    OP    INFANTS,  465 

mists,  and  among  them  M.  Geoffroy  St.-Hilaire,  have  established 
it  as  a  general  law  that  when  the  containing  part  is  deformed  or 
wanting,  all  the  contained  parts  are  at  the  same  time  but  little 
developed,  or  are  badly  formed.  But  several  contradictory  facts 
have  already  disturbed  this  principle,  and  I  could  myself  give  a 
very  remarkable  instance. 

Anencephalia  presents  different  degrees.  It  exists  from  a  spe- 
cies of  atrophy  of  the  cerebral  hemispheres,  which  is  seen  in 
ideots,  to  the  complete  absence  of  the  cerebral  mass.  I  have 
seen  it  in  several  degrees.  Thus,  I  once  saw  a  child  where  the 
forehead  and  summit  of  the  head  were  considerably  flattened. 
From  this  disposition  of  parts,  M.  Baron  made  a  diagnosis  of 
the  existence  of  anencephalia,  having  in  others  observed  the  same 
with  an  absence  of  brain  ;  and  upon  a  post  mortem  examination 
we  found  only  the  cerebellum,  thai  ami  nervorum  opticorum, 
the  third  and  fourth  ventricles :  the  fornix  was  separated  at  its 
middle.  The  posterior  part  of  the  hemispheres  was  sufficiently 
developed,  but  they  were  deficient  anteriorly,  leaving  exposed 
the  anterior  part  of  the  lateral  ventricles.  This  child  lived  forty 
days,  cried,  respired,  and  sucked  without  difficulty ;  this  case 
has  been  reported  at  length  in  my  thesis.*  I  have  also  seen  a 
child  who  came  into  the  world  with  the  cranium  very  irregu- 
larly developed  ;  there  was  no  doubt  of  this  being  a  case  of  anen- 
cephalia.  It  died  in  three  days,  and  on  opening  the  cavity  of  the 
cranium,  instead  of  finding  the  brain  regularly  formed,  there  was 
only  a  sac  formed  of  the  meninges,  on  the  surface  of  which  the 
vessels  appeared  as  usual;  this  sac  contained  a  bright  yellow 
fluid,  liquid  and  inodorous,  like  serosity.  When  it  had  flowed 
out,  the  cerebellum  could  be  seen  at  the  bottom  of  the  cranium, 
covered  by  the  tentorium,  the  rudiments  of  the  falx  cerebri,  the 
medulla  oblongata,  the  thalami  nervorum  opticorum,  and  the 
corpora  striata;  on  the  outside  of  these  floated  some  pulpous 
fragments,  which  appeared  to  be  the  rudiments  of  the  cerebral 
hemispheres.  The  pia  mater,  which  formed  the  internal  tunic 
of  this  cerebral  cyst,  was  covered  here  and  there  with  a  great 

*  See  the  dissertation  on  viability  at  the  end  of  this  work. 


59 


466  ON   THE    DISEASES    OF    INFANTS. 

number  of  pulpous  and  cerebiform  flakes,  which  it  was  said  had 
been  secreted  by  it.* 

In  this  case,  notwithstanding  the  integrity  of  the  bones  of  the 
cranium  and  the  considerable  number  of  vessels  of  this  organ, 
the  brain  only  existed  in  a  very  imperfect  state,  and  exhibited 
the  deformity  peculiar  to  anencephalia.  Anencephalia  had  not 
in  this  instance  been  caused  by  any  exterior  mechanical  influ- 
ence, nor  by  default  of  development  of  the  vascular  system, 
which,  according  to  the  doctrine  of  M.  Serres,  exists  before  the 
formation  of  the  organs  ;  and  every  thing  leads  to  the  belief  that 
a  dropsical  or  some  other  disease  of  the  brain  had  suspended  its 
development,  or  had  caused  its  disorganization,  at  a  period  more 
or  less  remote  from  its  formation.  But  what  is  more  important 
for  us  to  note  is  the  entire  absence  of  all  symptoms  which  would 
enable  us  to  recognise  the  existence  of  this  disorganization,  and 
the  continuance  of  life  for  so  long  a  time,  with  the  absence  of  so 
great  a  portion  of  this  important  organ. 

The  most  usual  degree  of  anencephalia  is  that  where  the  cra- 
nium and  the  brain  are  both  wanting,  the  upper  part  of  the  cra- 
nium being  open ;  the  ossa  frontis  are  wanting,  or  are  much 
mutilated,  and  there  is  scarcely  a  trace  of  the  ossa  parietalia.  A 
shapeless  cerebral  mass,  covered  by  red  and  bloody  membranes, 
is  situated  at  the  base  of  the  cranium,  which  is  usually  found 
nearer  the  shoulders  than  in  a  natural  state  ;  the  projection  of  the 
orbitar  arches  and  of  the  eyes,  the  face  which  presents  some 
analogy  to  that  of  the  head  of  certain  of  the  lower  animals,  to 
which  the  vulgar  will  sometimes  compare  these  children  ;  such 
are  the  ordinary  traits  of  an  anencephalous  infant,  in  whom  is 
often  found  nothing  more  than  the  medulla  oblongata,  and  some- 
times the  cerebellum,  and  the  remains  of  the  thalami  nervorum 
opticorum  and  corpora  striata.  The  causes  of  this  organic  devi- 
ation have  been  very  learnedly  discussed  by  Haller,  Sandifort, 
Soemmering,  Klein,  Otto,  Meckel,  Tiedemann,  Beclard,  Breschet, 
Geoffrey,  St.-Hilaire,  Serres,  and  Andral.  The  analytical  ex- 
amination of  the  facts  which  they  have  made  known,  and  the 
consequences  which  they  have  deduced  from  them,  would  re- 

*  M.  Breschet  has  given  some  analogous  facts  in  the  article  Hydrocephalies  in  the 
Diet,  de  med.,  in  21  vols. 


ON   THE    DISEASES   OP    INFANTS.  467 

quire  a  long  dissertation,  and  lead  us  too  far  from  the  main  object 
of  this  work.  1  will  therefore  draw  but  one  conclusion,  which 
is,  that  most  anencephalous  children,  even  though  born  before 
the  full  time,  and  being  otherwise  well  constituted,  have  for  the 
most  part  lived  one  day,  and  even  for  a  longer  time ;  and  have 
thereby  proved  that  it  is  sufficient  for  the  medulla  oblongata  and 
medulla  spinalis,  whence  arise  the  nerves  essential  to  organic 
life,  to  be  in  a  certain  state  of  integrity,  to  preserve  life  during 
the  foetal  evolution  and  for  some  time  after  birth. 

Congenital  hydrocephalus  is  in  all  probability  the  result  of  an 
inflammation  of  the  meninges  during  intra-uterine  life,  or  of  some 
malformation  difficult  to  ascertain,  bearing  some  resemblance  to 
a  nutritive  hyperthophy  of  the  encephalon.  This  idea  is  favored 
by  the  development  of  the  cerebral  mass  and  the  bones  of  the 
cranium  in  hydrocephalic  foetuses.  These  bones  acquire  a 
breadth  and  thickness,  not  only  resulting  from  inflammation  of 
the  meninges,  (this  circumstance  alone  cannot  explain  the  phe- 
nomenon,) but  it  evidently  shows  an  increase  of  nutrition,  which 
may  be  regarded  as  one  of  the  causes  of  hydrocephalus.  It  is 
worthy  of  remark,  that  after  birth,  children,  where  the  brain  and 
cranium  are  very  much  developed,  are  also  much  exposed  to 
hydrocephalus.  The  vital  activity,  or  the  power  of  nutrition 
developed  with  more  energy  than  in  a  natural  state,  ought  doubt- 
less to  be  taken  into  consideration,  as  one  of  the  possible  causes 
of  congenital  hydrocephalus. 

There  are,  however,  different  varieties  of  hydrocephalus :  that 
where  the  cranial  cavity  takes  no  part  in  the  dropsy  of  the  brain, 
the  substance  of  which  is  found  to  be  more  or  less  destroyed,  and 
this  was  the  case  in  the  instance  of  anencephalia  which  has  just 
been  mentioned ;  that  where  hydrocephalus  supervenes  at  a  more 
advanced  stage  of  foBtal  formation,  and  the  cranium  and  brain 
are  destroyed  or  deformed ;  and  lastly,  the  most  common  form  of 
the  disease,  that  where  there  is  with  it  a  considerable  develop- 
ment of  the  bones  of  the  cranium ;  this  last  variety  appears  to  me 
evidently  owing  to  a  kind  of  cerebral  and  cranial  hypertrophy, 
not  observed  in  other  cases.  This  nutritive  hypertrophy,  by  in- 
creasing the  power  of  formation  in  the  encephalic  mass,  will 
augment  the  activity  of  the  secretion  from  its  membranes;  hence 


468  ON   THE    DISEASES    OF    INFANTS. 

the  abundance  of  fluid  at  the  same  time  that  the  organ  augments 
in  volume. 

The  causes  of  the  normal  development  of  the  viscera  are  con- 
nected by  insensible  degrees  with  the  causes  of  their  anomalies, 
and  it  is  easily  conceived  how  it  happens  that  this  species  of  ve- 
getative life  with  which  our  organs  are  endowed  at4be  period  of 
their  formation,  on  receiving  an  increase  of  energy  may,  in  some 
way,  pass  the  limits  of  their  regular  state,  and  thus  cause  con- 
genital malformation,  which  ought  not  always  to  be  attributed 
to  diseases  similar  to  those  developed  after  birth.  If  we  can  as- 
certain that  monstrosities  supervene  when  the  development  is  ar- 
rested, why  may  we  not  attribute  certain  others  to  an  over- 
growth of  the  same  development  ? 

Be  this  as  it  may,  congenital  hydrocephalus  consists  in  a  very 
abundant  eff*usion  of  serosity  in  the  distended  ventricles  of  the 
brain,  the  size  of  which  is  increased  one  third  and  a  half,  and  the 
substance  of  which,  more  or  less  firm  at  the  circumference,  is  al- 
ways so  where  it  is  in  contact  with  the  fluid.  The  latter  does 
not  always  remain  enclosed  in  the  ventricles  ;  it  is  sometimes 
found  eff'used  in  the  arachnoid  cavity ;  hence  the  distinction, 
which  is  very  slight,  between  hydrocephalus  internus  and  hydro- 
cephalus externus. 

Thisdisease  often  coexists  with  hydrorachis ;  children  then  have 
one  or  more  tumors  along  the  vertebral  column,  and  an  enlarged 
head.  It  is  very  difiicult  to  tell  which  of  these  two  diseases  ex- 
ists primarily ;  perhaps  they  are  both  simultaneously  developed 
under  the  influence  of  the  same  cause.  Well-marked  inflamma- 
tion of  the  meninges  does  not  always  accompany  congenital  hydro- 
cephalus. Like  hydrorachis,  it  is  observed  to  arise  and  produce 
its  peculiar  symptoms  when  an  external  cause,  like  the  introduc- 
tion of  air  from  an  opening,  in  spina-bifida,  causes  an  irritation  of 
these  membranes,  which  is  generally  rapid  in  its  progress.  Hydro- 
cephalus may  exist  in  an  infant  at  birth  without  giving  rise  to 
any  morbid  symptom.  It  is  in  some  even  accompanied  with  a 
very  remarkable  degree  of  intellectual  activity,  and  this  is  an  addi- 
tional proof  of  the  truth  of  the  assertion  just  made  relative  to  the 
causes  of  this  anomaly.  Indeed  if  we  follow  for  a  greater  or  less 
time  the  causes  and  progress  of  this  disease,  we  shall  see  that  it  at 
first  consists  of  an  increase  of  organic  energy,  wliich  gives  to  the 


ON   THE    DISEASES    OP    INFANTS.  469^ 

brain  and  cranium  a  size  and  form  which  in  its  study  affords  so 
much  pleasure  to  physiologists,  because  it  is  the  presage  of  a 
high  intellect — a  presage  which  appears  to  be  well  founded,  as 
the  child  soon  astonishes  by  its  instinct,  the  justness  of  its  judg- 
ment, or  brilliancy  of  its  wit.  But  if  the  cause  of  such  organic 
and  functional  energy  continues  to  act,  it  reduces  both  the  organ 
and  its  functions  to  a  state  of  destruction  and  annihilation,  soon 
to  be  succeeded  by  death  itself 

Hydrocephalus  may  remain  stationary,  and  continue  to  an  ad- 
vanced period  of  life.  It  would  seem,  from  the  observations  of 
Camper,  that  children  in  whom  the  bones  of  the  cranium  are 
not  separated,  live  a  much  longer  time  than  those  in  whom  there 
exist  large  fontanelles  and  a  considerable  separation  of  the  su- 
tures of  the  bones.  It  often  coexists  with  a  congenital  malforma- 
tion of  the  vertebral  column,  or  of  the  limbs  ;  rendering  the  indi- 
viduals who  are  affected  with  it  either  idiots,  if  the  cerebral  sub- 
stance be  much  changed,  or  remarkable  for  their  genius,  if  it 
continues  in  a  slight  degree,  and  if  the  cerebral  activity  does  not 
exceed  the  limits,  to  us  unknown,  beyond  which  intellect  is  per- 
verted. It  is  useless  to  describe  the  form  of  the  cranium,  and  the 
expression  which  the  accumulation  of  water  in  the  ventricles 
imparts  to  the  physiognomy ;  the  fades  of  those  atfected  with 
hydrocephalus  is  well  known. 

I  believe  that  it  is  difficult  to  establish  a  proper  treatment  in 
this  disease.  How,  indeed,  can  the  nutritive  activity  be  suspend- 
ed in  the  affected  organ,  and  cause  the  absorption  of  the  effused 
fluid  ?  Yet  authors  have  advised  various  means  for  effecting 
this,  among  which  is  friction  with  mercurial  ointment  :  it  was 
for  the  first  time  employed  by  Armstrong ;  and  Lefebvre  de  Ville- 
brune  has  recorded,  in  his  translation  of  Underwood,  several 
cases  by  Armstrong  and  Hunter,  where  the  efficacy  of  this  method 
is  made  very  evident. 

But  it  is  to  be  remarked  that  the  subjects  of  these  cases  were 
of  an  advanced  age,  and  that  their  symptoms  were  more  proper- 
ly those  of  acute  or  chronic  meningitis,  than  of  a  simple  effusion 
of  serosity  in  the  cerebral  ventricles.  I  think,  therefore,  that  it 
is  useless  to  attempt  any  therapeutic  means  when  hydrocephalus 
causes  no  special  symptoms  ;  but  we  ought  to  confine  ourselves 
to  the  directions  of  hygiene,  the  object  of  which  will  be  to  re- 


470  ON   THE    DISEASES    OF    INFANTS. 

move  every  thing  that  would  increase  cerebral  excitement.  If 
meningitis  should  supervene,  we  must  have  recourse  to  the 
measures  already  advised  for  this  disease.* 

In  order  to  finish  the  history  of  congenital  diseases  of  the  cere- 
bro-spinal  apparatus,  it  remains  for  me  to  speak  of  fractures  and 
malformations  of  the  vertebral  column  and  bones  of  the  cranium. 

I  have  already  mentioned  the  default  in  the  union  of  the  spi- 
nous processes  of  the  vertebrae,  and  shall  now  say  a  word  on 
their  gibbosity.  This  is  of  rare  occurrence  in  infants  at  birth  ; 
but  it  is  usually  developed  after  that  period.  Yet  when  the  ver- 
tebral column  of  a  young  infant  is  examined,  a  peculiar  dis- 
position is  found  in  some,  and  v/hich  might  be  the  predisposing 
cause  of  the  malformation  of  which  I  am  speaking.  This  dispo- 
sition consists  in  a  sort  of  backward  displacement  of  one  or  seve- 
ral of  the  dorsal  vertebrae,  which,  instead  of  being  in  a  parallel 
line  with  the  others,  exhibit  a  slight  depression.  I  have  only  re- 
marked this  in  two  infants  at  birth,  and  this  disposition  was  per- 
haps the  commencement  of  gibbosity. 

The  bones  of  the  cranium  present,  in  infants  at  birth,  either 
malformations  or  solutions  of  continuity.  The  former  are  the 
result  of  an  arrest  of  development.  I  have  collected  three  cases 
of  remarkable  ossification  of  the  cranium  ;  the  osseous  fibres,  in- 
stead of  passing  from  the  centre  to  the  circumference  of  the  bone, 
were  interrupted  and  disposed  in  small  isolated  masses,  between 
which  was  found  a  cartilaginous  substance.  When  these  bones 
were  felt  through  the  integuments,  they  appeared  as  if  fractured 
or  ground.  In  another  instance,  I  found  in  a  new-born  child  a 
considerable  depression  at  the  anterior  inferior  part  of  the  right 
parietal  bone,  which  appeared  to  have  been  produced  by  some 
mechanical  compressive  cause  applied  to  the  cranium  during  the 
process  of  ossification. 

Lastly,  the  bones  of  the  cranium  are  subject  to  present  frac- 
tures in  different  parts,  when  the  head  has  undergone  much  diffi- 

*  To  the  alterations  of  the  brain,  which  we  have  just  studied,  we  may  subjoin,  as 
an  instance  of  congenital  hypertrophy  of  the  dependant  parts  of  the  brain,  the  two  facts 
reported  by  Chaussier.  In  an  infant  stillborn,  the  head  of  which  was  well  formed,  he 
found  the  pineal  gland  compact,  elongated,  and  as  large  as  the  extremity  of  the  little 
finger  of  an  adult.  In  another  it  was  larger  than  in  adults.  Proces  verbal  de  la  dis- 
tribution der.  prix  aux  cleves  sages-femmcs  de  la  MaUrnite,  1812.    (See  Appendix.) 


ON   THE   DISEASES   OP    INFANTS.  471 

culty  in  passing-  through  the  straits  of  the  pelvis,  or  when  we 
have  been  compelled  to  terminate  the  labor  by  the  use  of  forceps. 
Professor  Chaussier  and  M.  Duges  long  since  published  in- 
stances of  this  kind  of  lesion.  These  fractures  are  almost  al- 
ways accompanied  with  cerebral  congestion  or  apoplexy ;  this 
complication  ought  to  fix  the  attention  of  the  practitioner  more 
than  the  fracture. 

The  bones  of  the  cranium  sometimes  leave  between  them 
large  spaces,  either  because  they  are  not  sufficiently  developed  by 
reason  of  the  great  size  of  the  brain,  as  is  observed  in  hydroce- 
phalus, or  because  the  development  has  been  arrested.  The  fon- 
tanelles  are,  in  consequence  of  this,  very  much  spread,  allowing 
a  greater  or  less  quantity  of  the  brain  to  project,  forming  a  real 
hernia.  This  disease  is  a  very  serious  oiie  ;  it  almost  always  co- 
exists with  hydrocephalus,  the  progress  of  which  soon  causes  the 
death  of  the  child.  The  nature  of  this  hernia  is  easily  ascertain- 
ed, particularly  from  its  situation,  for  it  always  occupies  a  point 
corresponding  with  one  of  the  fontanelles,  and  principally  to  the 
superior  and  anterior  one.  We  must  be  careful  neither  to  com- 
press nor  pierce  this  tumor ;  it  ought  to  be  loosely  covered,  that 
the  friction  of  the  clothes  or  of  external  bodies  may  not  pro- 
duce excoriation  and  inflammation.  There  is  another  species 
of  hernia,  which  is  much  more  rare,  and  I  have  met  with  but 
one  instance  of  it,  and  1  am  not  aware  of  any  thing  similar  in  the 
works  of  authors. 

CASE  LXXX. — Congenital  malformation,  hernia  of  the  brain. 
— Marianne  Masse,  aged  one  day,  entered  the  infirmary  on  the  22d 
of  June ;  she  was  of  medium  strength ;  the  integuments  were 
very  red  ;  she  had  no  other  symptom  than  diarrhoea  ;  the  cry  was 
strong,  and  the  respiration  free.  She  had  on  the  lateral  part  of  the 
left  side  of  the  face,  before  the  ear,  a  tumor  half  an  inch  in  diameter, 
very  round,  more  projecting  inferiorly  than  superiorly,  where  it  was 
confounded  with  the  skin  of  the  cranium,  whilst  inferiorly  it  pre- 
sented a  circumscribed  prominent  border.  The  integuments  cover- 
ing it  were  healthy,  and  of  a  vermilion  color,  like  the  rest  of  the 
face.  It  was  painful  and  slightly  soft  to  the  touch ;  the  forehead, 
very  much  depressed  above,  formed  a  considerable  prominence  in 
front ;  the  eyelids  were  sunk  in  the  orbits,  and  their  approximation 


472  ON   THE    DISEASES    OF    INFANTS. 

prevented  the  globe  of  the  eye  from  being  distinguished  ;  an  oblong 
vermilion  cicatrix,  with  slightly  prominent  edges,  and  apparently  but 
recently  consolidated,  existed  at  the  left  lateral  part  of  the  cranium. 
This  child  remained  in  the  infirmary  until  the  20th  of  July,  when 
she  died. 

On  opening  the  body,  there  was  found  an  acute  inflammation  of 
the  digestive  tube  ;  the  respiratory  apparatus  was  healthy. 

The  left  hemisphere  of  the  brain  was  about  one  third  less  than  the 
right.  Neither  the  longitudinal  sinus  nor  the  falx  of  the  brain  were 
found  upon  the  median  line  of  the  cranium,  but  they  were  directed 
obliquely  from  the  centre  of  the  forehead  to  the  lateral  left  part  of 
the  occipital  fossa  ;  all  the  left  portion  of  the  hemisphere,  which  is 
usually  lodged  in  the  middle  lateral  fossa  of  the  base  of  the  cranium, 
was  thrown  backward  in  a  species  of  sac,  formed  of  the  tunica  arach- 
noidea,  the  dura  mater,  and  the  skin.  This  portion  of  the  brain 
formed  the  tumor  of  which  I  have  spoken  ;  it  issued  from  the  cra- 
nial cavity  by  a  tolerably  large  opening,  which  resulted  from  the  ab- 
sence of  the  squamous  portion  of  the  temporal  bone.  This  portion 
consisted  of  nothing  but  an  edge  of  not  more  than  two  lines  in  ex- 
tent, and  which  was  curled  below  like  the  shell  of  a  snail  ;  the  an- 
gle of  the  parietal  bone  existed,  and  formed  the  upper  part  of  the 
opening.  The  meninges  and  the  cerebral  substance  were  very  much 
injected. 

This  hernia  was  evidently  the  result  of  compression  which  the 
cranium  and  brain  had  experienced  during  intra-uterine  life  ;  the 
defect  in  the  development  of  the  squamous  portion  of  the  tem- 
poral bone  was  doubtless  caused  by  the  compression  which  the 
corresponding  part  of  the  brain  had  exercised  on  it.  I  have  al- 
ready considered  some  of  the  possible  causes  of  this  hernia, 
when  speaking  of  the  congenital  diseases  of  the  skin. 

Art.  2. — Diseases  of  the  cerebro-spinal  apparatus,  developed  after  birth. 

§  I.  Congestions. — Passive  congestions  of  the  cerebro-spinal 
apparatus  are  very  common  in  infants  at  birth.  This  arises  from 
the  abundance  of  vessels,  the  slowness  of  the  circulation,  and  the 
influence  of  respiration  on  the  spinal  and  cerebral  circulation. 
The  length  of  the  labor,  the  necessary  tractions  in  certain  ma- 
noeuvres, the  difiiculty  with  which  respiration  is  established,  the 
changes  which  the  circulation  undergoes,  explain  how  this  ap- 


ON   THE    DISEASES    OF    INFANTS.  473 

paratiis  is  so  often  the  seat  of  sanguineous  congestions,  varying 
from  simple  injection  of  the  meninges  to  true  apoplexy. 

By  the  general  term  apoplexy  in  new-born  children,  is  meant 
several  degrees  of  cerebral  congestion  ;  and  for  the  most  part, 
children  dying  in  an  apoplectic  state  do  not,  on  a  post  mortem 
examination,  exhibit  the  effusion  of  blood,  or  the  circumscribed 
cerebral  hemorrhage  which  constitutes  the  disease  described  under 
the  same  name  in  adults.  Let  us,  therefore,  consider  the  various 
lesions  which  belong  to  this  disease. 

Injection  of  the  meninges,  of  the  medulla,  and  of  the  brain, 
is  so  common  in  infants  at  birth,  that  it  has  appeared  to  me  more 
proper  to  consider  it  as  a  natural  rather  than  as  a  pathological 
state.  It  is  found  in  most  dead  bodies  ;  vascular  injection,  and 
even  effusion  of  blood  at  the  inferior  and  posterior  extremity  of 
the  spine,  are  very  frequent.  I  have  often  seen  it  without  its 
having  given  rise,  during  life,  to  any  appreciable  symptom. 

If  the  injection  is  continued  too  long,  it  will  soon  produce  an 
exudation  on  the  surface  of  the  meninges ;  and  the  blood  which 
is  the  product  of  this  exhalation,  is  ordinarily  coagulated  in  a 
greater  or  less  quantity,  compressing  the  brain  and  spinal  mar- 
row, and  causing  the  state  of  stupor  to  follow  which  is  character- 
istic of  apoplexy.  This  hemorrhage,  exterior  to  the  cerebral  mass, 
is  almost  always  met  with  in  infants  who  have  died  of  apoplexy. 
This  is  what  M.  Serres  calls  meningeal  apoplexy,  and  which  he 
attributes  to  the  rupture  of  some  one  of  the  vascular  branches 
which  wind  over  the  surface  of  the  brain. 

Injection  of  the  cerebral  pulp  is  equally  common ;  it  exists 
under  the  form  of  a  spotted  redness,  sometimes  coloring  deeply 
the  substance  of  the  brain  ;  it  usually  exists  on  the  lateral  parts 
of  the  corpora  striata  and  thalami  nervorum  opticorum.  It  is  in 
this  part  that  the  cerebral  vessels  exist  in  the  greatest  abundance, 
and  which  is  more  generally  affected  with  hemorrhage  and  in- 
flammation at  every  period  of  life  ;  the  works  of  Morgagni,  and 
the  recent  researches  of  MM.  Lallemand*  and  Bouillaud,t  have 
rendered  this  fact  incontestible. 

Lastly,  it  is  possible,  but  it  is  very  rare,  to  find  cerebral  hemor- 

♦  Recherches  anatomico-pathologiques  sur  Vencephale  etses  dependances, Paris,  1820, 
1829.    Letters  1  to  6. 

t  Traite  de  Vencephalite  ou  inflammation  du  cerveau  et  de  ses  suites.     Paris,  1815. 


474  ON   THE    DISEASES    OF    INFANTS. 

rhage  very  circumscribed ;  I  have  met  with  but  one  case  of  it. 
This  child  died  on  the  third  day  after  birth,  with  symptoms  of 
apoplexy.  On  a  post  mortem  examination,  there  was  found  a 
sanguineous  effusion  in  the  left  hemisphere,  on  the  lateral  parts 
of  the  corpora  striata.  There  was  no  apparent  cyst ;  the  cere- 
bral substance  was  a  little  softened  in  points  which  surrounded 
the  effusion,  the  extent  of  which  was  one  inch  in  length  by  half 
an  inch  in  breadth.* 

§  II.  Non-inflammatory  softening. — This  is  a  lesion  pe- 
culiar to  the  encephalon  of  new-born  children,  and  is  the  result 
of  congestion  of  this  organ.  This  is  a  species  of  softening  either 
general  or  local,  which,  far  from  presenting  the  characters  of  in- 
flammation, on  the  contrary  presents  all  the  signs  indicating  de- 
composition, and  we  might  almost  say  putrefaction,  of  this  organ. 
I  will  here  give  an  instance  of  this  affection. 

CASE  LXXXI. — Alexis  Louart,  aged  three  days,  entered  the  in- 
firmary on  the  18th  of  May.  He  was  affected  with  a  general  indura- 
tion of  the  cellular  tissue  ;  the  integuments  were  of  a  violet  red  in  all 
parts  of  the  body  ;  the  cry  was  smothered,  painful,  and,  at  times,  very 
acute.  The  chest  sounded  obscurely.  He  was,  besides,  affected  with 
a  very  abundant  diarrhoea.  The  pulsations  of  the  heart  were  quick, 
but  of  extreme  smallness.  There  was  no  change  in  his  condition  on 
the  succeeding  day,  and  he  died  on  the  twenty-first.  On  a  post  mor- 
tem examination,  the  digestive  apparatus  was  found  injected  in  al- 
most its  entire  extent.  The  liver  was  gorged  with  black  and  fluid 
blood  ;  its  tissue  was  hard  and  of  a  brown  slate  color ;  the  lungs 
were  floccid,  blackish,  slightly  dilated  with  air,  and  gorged  with 
blood  at  their  posterior  edge.  The  foetal  openings  still  existed  ;  the 
meninges  were  very  much  injected ;  the  cerebral  pulp  was  red,  and 
reduced  to  a  soft  mass,  which  flowed  freely  on  making  an  incision 
into  the  arachnoid  membrane,  diffusing  a  very  evident  odor  of  sul- 
phuretted hydrogen.  This  softening  extended  even  to  the  lateral 
ventricles,  where  was  found  a  quantity  of  effused  blood ;  the  rest  of 

♦  A  fact  observed  by  M.  Berard,  junior,  proves  that  cerebral  hemorrhage  may  occur 
during  intra-uterine  life ;  so  that  apoplexy  ought  to  be  mentioned  among  the  number  of 
diseases  by  which  an  infant  may  perish  before  birth,  and  bring  on  labor  before  the 
tune.  The  fcetus  in  which  M.  Berard  has  observed  this  remarkable  alteration,  was 
aged  eight  months  and  a  half;  the  clot,  about  the  size  of  a  nut,  was  lodged  in  the  sub- 
stance of  the  brain.     Socitte  anatomiquc,  1828. 

56 


ON    THE    DISEASES    OF    INFANTS.  475 

tne  brain  was  softened,  and  of  a  violet  color,  but  was  far  from  being 
soft,  like  that  part  of  the  hemispheres  above  the  ventricles. 

Here  it  is  evident  that  this  general  disorganization  of  the  cere- 
bral pulp  was  the  result  of  its  contact  and  mixture  with  the 
blood  effused  in  the  ventricles,  and  infiltrated  in  the  proper  sub- 
stance of  the  brain ;  for  there  almost  always  exists  cerebral  hem- 
orrhage at  the  same  time ;  but  this  hemorrhage,  when  recent, 
may  exist  alone,  without  any  softening  of  the  brain ;  there  is 
only  observed,  at  the  superior  part  of  the  hemisphere,  or  at  the 
corpora  striata,  the  points  of  the  encephalon,  where  the  softening 
commences,  and  which  already  diffuses  the  odor  peculiar  to  this 
disorganization.  On  the  other  hand,  I  am  disposed  to  believe 
that  the  cerebral  softening  may  precede  the  hemorrhage,  and  may 
even  produce  it,  for  I  have  several  times  found  it  without  san- 
guineous effusion. 

The  softening  of  which  1  speak  sometimes  exists  only  in  one 
lobe,  at  other  times  in  both  ;  very  often  the  whole  of  the  cerebral 
mass  is  so  destroyed,  that  nothing  more  is  found  on  opening  the 
cranium  but  a  soft  floculent  black  mass,  mixed  with  a  great  num- 
ber of  clots  of  blood  and  pulpy  flakes.  It  is  a  remarkable  fact 
that  the  meninges  are  not  involved  in.  this  disorganization,  and 
that  notwithstanding  this  destruction  of  the  encephalon,  children 
will  still  live  some  days,  not  possessing  simply,  as  is  vulgarly 
thought,  a  mere  breath  of  life,  but  actually  respiring,  crying,  and 
sucking ;  this  occurs  when  the  disorganization  is  arrested  at  the 
medulla  oblongata,  which  remains  unaffected,  and  which,  with 
the  medulla  spinalis,  controls  the  phenomena  of  life,  even  pre- 
serving it  for  some  time. 

I  have  often  found  this  softening  in  new-born  children  that 
died  immediately  after  birth,  leading  to  the  belief  that  it  had  its 
existence  during  the  sojourn  of  the  child  within  the  womb. 

"When  the  medulla  oblongata  and  medulla  spinalis  are  thus 
softened,  the  child  exhibits  much  less  vital  activity ;  the  limbs  are 
completely  flaccid  and  immoveable  ;  the  cry  is  altogether  annihi- 
lated ;  the  pulsations  of  the  heart  scarcely  perceptible ;  the 
limbs  are  cold,  and  deglutition  almost  impossible.  The  child 
soon  sinks  under  this  state  of  feebleness,  and  the  post  mor- 
tem examination  reveals  the  disorganization  of  the  entire  ner- 


476  ON    THE    DISEASES    OF    INFANTS, 

vous  centre,  and  thus  explains  the  symptoms  and  death  of  the 
child. 

This  softening  is  more  frequent  on  the  lateral  parts  of  the 
hemispheres  and  near  the  corpora  striata,  than  at  any  other  part 
of  the  brain.  These  symptoms  are  serious  in  proportion  to  their 
extent,  and  to  their  approximation  to  the  medulla  oblongata;  the 
prognosis  is  a  very  unfavorable  one,  for  death  appears  to  me  to 
be  inevitable. 

Such  are  the  assemblage  of  the  lesions,  which  the  different 
stages  and  varieties  of  cerebral  congestion  in  new-born  children 
may  present.  The  symptoms  are  usually  characterized  by  a 
state  of  sinking,  prostration,  and  sanguineous  congestion  of  the 
limbs,  body,  and  face,  and  especially  by  the  proper  signs  of  pul- 
monary congestion,  which  almost  always  accompanies  that  of 
the  brain.  It  is  difficult  in  young  infants  to  ascertain  the  pecu- 
liar eifects  of  apoplexy  of  the  right  or  left  hemisphere  on  the 
opposite  side  of  the  body  ;  for,  as.  I  have  observed  when  speaking 
of  the  development  of  the  brain,  this  organ  at  the  time  of  birth 
can  hardly  be, said  to  be  formed;  it  neither  enjoys  as  yet  the 
organic  form  nor  the  vital  properties  which  it  acquires  in  the 
progress  of  its  development. 

The  treatment  of  cerebral  congestions  ought  to  be  confined  to 
sanguineous  evacuations,  produced  by  causing  the  blood  to  flow 
by  the  umbilical  cord  in  infants,  at  the  period  of  birth,  or  by  the 
application  of  two,  three,  or  four  leeches  to  the  base  of  the  cra- 
nium. Every  thing  that  can  excite  and  accelerate  the  move- 
ments of  the  circulation  ought  to  be  removed. 

Art,  3. — Inflammation  of  the  Cerebro-spinal  Apparatus. 

It  is  without  doubt  a  great  advantage  that  the  brain  in  chil- 
dren is  one  of  the  last  of  the  viscera  that  becomes  organized; 
for  if  at  the  period  of  birth  it  possessed  all  the  organic  and  vital 
properties  which  is  observed  in  the  digestive  or  respiratory  appa- 
ratus, it  would  be  exposed  to  frequent  inflammations.  But  its 
pulpous,  and,  we  might  almost  say,  inorganic  state,  renders  it 
but  little  disposed  to  phlegmasia,  which  might  be  developed  after 
the  congestions  of  which  it  is  always  the  seat  at  the  time  of  birth. 
I  can  therefore  affirm  that  well-marked  inflammation  of  the  cere- 


ON   THE    DISEASES    OF    INFANTS.  477 

bral  substance  is  rare  in  new-born  children.  That  of  the  me- 
ninges is  more  common  ;  let  us,  then,  commence  with  the  study 
of  meningitis. 

§  I.  Spinal  meningitis— Inflammations  of  the  spinal  meninges 
are  always  more  frequent  than  those  of  the  medulla;  they  give 
rise  to  convulsions  of  the  limbs,  and  sometimes  of  the  face,  par- 
ticularly if  the  inflammation  be  situated  near  the  base  of  the 
brain.  In  thirty  cases  of  convulsions  in  new-born  children,  I 
have  found  in  twenty  cases  a  well-marked  inflammation  of  the 
meninges  of  the  spine,  and  in  these  twenty  cases  there  were  six 
with  inflammation  of  the  meninges  of  the  brain  and  of  the  spinal 
marrow;  so  that  it  is  probable  that  convulsions  of  infants  are 
almost  always  the  result  of  an  irritation  or  inflammation  of  the 
rachidian  meninges.  The  following  case  exhibits  the  develop- 
ment and  the  progress  of  the  symptoms  of  meningitis. 

CASE  LXXXII. — Louis  Russel,  aged  three  days,  entered  the  in- 
firmary on  the  3d  of  September.  During  the  preceding  night  he  had 
been  attacked  with  convulsions,  which  continued  until  morning. 
His  limbs  were  rigid  and  violently  bent;  the  muscles  of  the  face 
were  in  a  continual  state  of  contraction;  the  pulse  was  full,  strong, 
and  frequent.  [Two  leeches  to  the  mastoidean  region,  sweetened 
decoction  of  linden,  sinapisms  to  the  feet.)  The  convulsions  dimin- 
ished, without  ceasing  altogether,  immediately  after  the  application 
of  the  leeches.  '  The  child  was  very  feeble,  and  respired  with  difli- 
culty,  and  discharged  a  quantity  of  frothy  saliva  from  the  mouth. 
(Sweetened  barley-water,  cataplasm  to  the  feet.)  On  the  morning 
of  the  fourth,  the  convulsions  returned  with  increased  intensity  ;  the 
pulse  was  quickened,  the  integuments  very  hot.  The  feeble  condi- 
tion of  the  child  forbade  the  application  of  leeches,  and  the  treatment 
was  confined  to  the  application  of  cold  to  the  head.  The  convulsions 
continued  during  the  whole  day ;  the  body  remained  rigid,  and  the 
vertebral  column,  which  the  weight  of  the  trunk  will  cause  to  bend 
with  the  greatest  ease  in  a  young  infant,  remained  straight  and  im- 
moveable whenever  the  child  was  raised.  The  cry  was  very  acute ; 
the  muscles  of  the  face  contracted  with  the  same  force  as  before,  and 
they  appeared  a  little  more  drawn  to  the  left  side.  In  the  evening, 
the  child  sunk,  became  cold,  with  a  small,  intermittent  pulse,  and 
died  during  the  night. 

Post  mortem  examination. — General  paleness  of  the  teguments, 


478  ON   THE    DISEASES    OF    INFANTS. 

spotted  redness  of  the  stomach,  discoloration  of  the  mucous  mem- 
brane of  the  small  intestines,  tumefied  and  red  follicles  in  the  large 
intestines.  A  large  quantity  of  effused  blood  appeared  on  the  sur- 
face of  the  right  hemisphere  of  the  brain,  and  a  sanguineous  serosity 
in  the  lateral  ventricles  at  the  base  of  the  cranium.  The  meninges 
of  the  brain  were  pale,  those  of  the  spine  very  much  injected,  and  on 
the  surface  of  the  tunica  arachnoidea  appeared  a  very  thick,  pelli- 
cular exudation ;  this  coating  was  very  easily  raised,  leaving  the 
membrane  beneath  covered  with  red  points,  without  any  alteration 
of  tissue. 

Such  are  the  symptoms  and  lesions  usually  presented  by  spinal 
meningitis.  Yet  it  is  possible  that  there  may  exist  simple  irrita- 
tion without  exhibiting,  on  opening  the  body,  any  apparent  in- 
flammatory lesions.  It  is  not  unusual  to  find  after  convulsions 
in  children  nothing  more,  as  in  adults,  than  simple  injection  of 
the  meninges ;  but  ought  we  doubt  that  this  is  the  seat  of  the 
disease  ;  and  do  we  not  see  that  there  is  in  this  case  only  a  dif- 
ference in  degree  from  the  slightest  irritation  to  the  highest  stage 
of  inflammation,  the  progress  of  which  generally  leads  to  lesions, 
which  aflfbrd  incontestible  proof  of  the  nature  of  the  disease? 

The  spinal  meninges  may  participate  in  the  inflammation  of 
all  the  serous  membranes.  I  once  found,  in  a  child  that  died 
three  days  after  birth,  peritonitis,  pleuritis,  and  rachidian  me- 
ningitis. 

Inflammation  of  the  meninges  almost  always  gives  rise,  even  in 
very  young  infants,  to  an  elevation  and  frequency  of  the  pulse  ; 
febrile  reaction  is  more  evident  in  these  afiections  than  in  phleg- 
masiae  of  the  thorax  or  abdomen  ;  yet  I  have  sometimes  found 
the  pulse  slow  and  depressed ;  but  when  this  is  the  case,  the 
physiognomy  of  the  child  always  expresses  great  pain  and  anx- 
iety. There  also  exists  at  times  a  very  laborious  respiration,  as 
is  shown  by  lividity  of  the  face  and  Umbs,  and  by  the  slow  dila- 
tation of  the  thoracic  parietes. 

§  II.  Cerebral  meningitis. — The  symptoms  of  arachnitis  of  the 
brain  differ  but  little  from  those  of  inflammation  of  the  rachidian 
meninges.  It  is  much  more  common  at  the  base  than  at  the 
upper  part  of  this  organ,  and  the  only  alteration  which  is  found 
in  children  that  die  from  this  phlegmasia  often  consists  of  no- 


ON  THE   DISEASES   OP    INFANTS.  479 

thing  more  than  a  peUicular  exudation,  more  or  less  thick,  ap- 
plied in  irregular  layers  on  the  surflice  of  the  arachnoid  mem- 
brane, corresponding  with  the  base  of  the  cranium.  These 
concretions  are  almost  always  found  beneath  the  tunica  arach- 
noidea  and  pia  mater. 

One  of  the  most  immediate  effects  of  cerebral  meningitis  is 
the  effusion  of  serosity  in  the  ventricles.  This  effusion,  desig- 
nated by  authors  under  the  name  of  hydrocephalus  aciitus,  often 
takes  place  before  the  formation  of  pellicular  concretions,  and 
even  when  the  inflammation  of  the  membrane  exists,  still  under 
the  form  of  a  simple  injection  ;  so  that  many  authors,  attaching 
more  importance  to  the  symptom  than  to  the  cause  producing 
it,  have  confined  themselves  to  describing,  under  the  title  of  hy- 
drocephalus acutus,  this  form  or  variety  of  rachidian  phlegma- 
sia ;  but  the  interesting  works  of  MM.  Bricheteau,  Guersnet, 
Senn,  Goelis,  and  others,  have  demonstrated  very  clearly  the  per- 
fect coincidence  existing  between  arachnitis  and  hydrocephalus  j 
and  on  this  account  it  appears  to  me  proper  to  consider  the  dis- 
ease in  this  place,  instead  of  making  it  the  subject  of  another 
chapter. 

The  effusion  of  serosity  in  the  ventricles  of  the  brain  occurs 
very  quickly  in  infants.  The  slightest  meningeal  or  cerebral 
irrittition  will  effect  it,  and  as  the  sudden  presence  of  this  water 
in  the  ventricles  produces,  either  by  its  contact  or  by  the  pres- 
sure and  distension  which  it  creates,  a  greater  degree  of  pain 
and  a  new  train  of  symptoms,  meningitis,  or  encephalitis  com- 
plicated with  hydrocephalus,  then  assumes  its  peculiar  character. 

Indeed,  to  the  restlessness  and  convulsions  which  appear  at 
the  commencement  of  this  disease,  follows  suddenly  the  greatest 
excitement ;  the  child  by  its  acute  cries  expresses  the  violence 
of  its  pain,  which  for  a  moment  ceases,  to  be  renewed  with  in- 
creased intensity.  This  remission  in  the  symptoms  is  very  re- 
markable ;  it  sometimes  observes  a  periodical  return,  and  it  is 
this,  without  doubt,  that  has  induced  some  authors  to  describe 
the  hydrocephalic  fever  as  intermittent.  But  this  remission  is 
common  to  all  excessively  painful  diseases,  and  especially  to 
such  as  produce  some  lesions  of  the  nervous  system ;  this  is  a 
fact  worthy  of  observation,  and  which  deserves  consideration  in 
the  history  of  every  periodical  irritation.     When  the  effusion  is 


480  ON   THE    DISEASES    OF    INFANTS. 

considerable,  the  convulsions  are  less  ;  the  limbs,  which  were 
very  remarkable  for  their  spasmodic  rigidity,  become  completely 
flexible  ;  the  face  assumes  a  peculiar  expression,  arising  from  the 
permanent  dilatation  of  the  pupils,  and  the  fixed  dull  stare  of  the 
child ;  the  pulse,  which  was  remarkable  for  its  frequency  and 
quickness,  becomes  very  slow,  and  is  scarcely  perceptible.  Yet 
the  child  will  sometimes  of  a  sudden  come  out  of  this  state  of 
prostration,  and  a  new  state  of  excitement  shows  itself;  the 
limbs  are  convulsed  anew,  the  globe  of  the  eye  becomes  the  seat 
of  spasmodic  movements;  but  this  exacerbation  is  of  short  dura- 
tion, and  is  soon  replaced  by  a  state  of  coma,  which  usually 
continues  until  death.  Children  a  little  older  than  those  whose 
pathology  I  am  considering,  exhibit  other  symptoms  deserving 
the  attention  of  the  physician  ;  such  especially  is  the  pain  in  the 
head,  which  gives  to  the  child  the  sensation  of  something  sepa- 
rating the  bones  of  the  cranium,  an  expression  which  I  have 
heard  a  child  of  six  years  of  age  use,  and  in  order  to  convey 
some  idea  of  the  suffering,  compared  it  to  that  which  might  be 
produced  by  driving  a  wedge  violently  in  the  head,  to  separate  it 
in  dilferent  directions. 

The  secondary  symptoms,  or  those  which  do  not  depend  di- 
rectly on  acute  hydrocephalus  in  young  infants,  are  vomiting, 
difficulty  of  respiration,  and  angina,  with  alteration  of  the  tone 
of  the  cry.  This  last  affection  doubtless  arises  from  the  violence 
and  frequency  of  the  cries.  There  often  exists,  also,  an  obsti- 
nate constipation. 

Sometimes  hydrocephalus  becomes  chronic,  after  having  pre- 
sented the  usual  symptoms  of  the  acute  form  of  the  disease. 
The  patient  then  falls  into  a  state  of  stupor  and  idiocy,  which 
continues  during  the  remainder  of  life. 

The  anatomical  lesions  which  appear  on  examining  the  body 
are  numerous  and  variable.  In  a  few  of  the  cases,  nothing  is 
found  but  a  simple  vascular  injection  of  the  meninges,  together 
with  more  or  less  clear  serosity  in  the  ventricles.  Ought  this  to 
be  considered  as  hydrocephalus  without  meningitis  ?  I  think  it 
ought  not ;  inflammation  does  not  always  cause  the  pathological 
alterations  which  characterize  it  from  the  first  period  of  its  ex- 
istence ;  we  can  see  every  day  meningitis  and  encephalitis  char- 
acterized, during  life,  by  the  most  marked  symptoffis,  without  of- 


ON   THE    DISEASES    OP    INFANTS.  425 

croup,  or  the  latter  disease  may  be  developed  in  the  middle  of 
hooping-cough  prevailing  epidemically ;  so  that  the  usual  causes 
giving  rise  to  simple  catarrh,  croup,  or  hooping-cough,  appear  to 
be  connected  by  relations  and  analogies,  the  characters  of  which 
escape  us,  it  is  true,  but  which  allow  us  to  see  their  simultaneous 
or  consecutive  effects.  During  the  time  I  was  at  the  Hospice 
des  Enfans  Trouves,  I  saw  at  the  house  of  a  nurse  who  lived 
near  the  "  barriere  d'Enfer,"  three  children,  aged  from  ten  to 
eighteen  months,  who  were  affected  in  the  space  of  three  months 
with  measles,  accompanied  by  a  slight  anginose  affection,  simple 
bronchial  catarrh,  which  soon  assumed  the  characters  of  hooping- 
cough,  and  lastly  with  croup  ;  all  these  occurred  successively  in 
three  children,  and  cut  them  off  in  eight  days. 

It  is  difficult  for  us  positively  to  ascertain  the  nature  of  hoop- 
ing-cough, but  we  may  still  obtain  some  knowledge  of  its  prin- 
cipal characters.  Thus  it  is  evident  that  it  is  a  bronchial  ca- 
tarrh, which  can  be  discovered  by  the  most  superficial  examina- 
tion of  the  symptoms  of  the  patient.  This  catarrh,  however,  has 
something  peculiar  ;  the  cough  which  it  produces  is  always  suf- 
focating, convulsive,  and  only  occurs  in  paroxysms.  This  ner- 
vous complication  is  to  be  noted,  for  here  its  specific  character 
commences,  and  we  can  see  it,  but  are  unable  to  explain  it  with- 
out hazarding  the  danger  of  wandering  into  futile  hypotheses ; 
yet  I  will  make  one  remark  in  relation  to  this  nervous  complica- 
tion ;  it  is,  that  in  adults,  as  well  as  in  children,  affections  of  the 
trachea,  larynx,  and  also  of  the  bronchia,  often  give  rise  to  a  sud- 
den local  or  general  spasmodic  irritation,  characterized  by  spasm 
of  the  affected  organ,  or  by  general  convulsions.  Tonsilitis,  sim- 
ple angina,  croup,  foreign  bodies  in  the  trachea,  or  tumors  com- 
pressing the  trachea  or  bronchiae,  produce  a  cough  more  or  less 
suffocating,  very  remarkable  for  its  remissions,  and  which,  in 
some  cases,  has  a  striking  resemblance  to  that  of  hooping-cough. 
Admitting,  therefore,  the  specific  nature  of  catarrh  in  this  dis- 
ease, and  that  it  consists  especially  in  a  nervous  complication, 
we  are  disposed  to  the  opinion  that,  in  many  other  instances, 
the  diseases  of  the  same  organ  may  exhibit  very  evidently  a  ner- 
vous complication ;  whence  it  will  follow,  that  if  in  a  similar 
complication  consists  the  specific  nature  of  hooping-cough,  the 
seat  of  the  disease  and  the  physiological  lesion  which  exists  be- 

54 


426  ON   THE    DISEASES    OF    INFANTS. 

tween  it  and  the  nervous  system,  may  concur  in  a  manner  that 
will  produce  the  specific  quality  of  the  disease  in  question.  The 
same  disease,  in  different  parts  of  the  system,  often  presents  va- 
rious characters ;  different  diseases  having  the  same  seat,  some- 
times exhibit  analogous  characters  ;  the  seat  of  the  affection  then 
has  something  that  imparts  a  specific  quality  to  diseases  in  gene- 
ral, and  ought  to  be  considered  when  treating  them. 

There  is  also  another  circumstance  which  ought  to  be  consi- 
dered as  peculiar  to  hooping-cough — that  is,  the  coexistence  of 
mucous  vomitings,  effected  by  the  cough.  This  coexistence  is 
easily  explained  by  the  relation  existing  between  the  mucous 
membrane  of  the  bronchise  and  that  of  the  stomach,  and  the  fre- 
quency of  the  cough  very  naturally  accounts  for  the  frequency 
of  vomiting. 

I  do  not  pretend  that  I  have,  by  the  preceding  explanation, 
satisfactorily  accounted  for  the  specific  nature  of  hooping-cough, 
but  have  only  endeavored  to  exhibit  one  of  the  possible  causes 
of  it ;  and  there  remains  sufficient  to  call  forth  all  our  efforts  to 
unveil  the  nature  of  this  disease.  Some  of  the  most  enlightened 
observers  have  exercised  their  talents  in  the  investigation  of  this 
subject;  such  as  Rosen,  Cullen,  Schoefer,  Hufeland,  Mathai, 
John,  Authenrieth,  Baumes.  All  have  discovered,  on  examining 
the  bodies  of  those  who  have  died  of  this  disease,' the  existence 
of  bronchial  catarrh,  without  any  particular  lesion  of  the  bron- 
chise.  This  opinion  is  sustained  particularly  by  Dr.  Watt,  of 
Glasgow,*  Albers  of  Bremen,  Marcus,t  Desruelles,t  and  Ad. 
Hencke,  who  in  his  learned  work  appears  to  adopt  the  same 
opinion.  § 

Hufeland  thinks  that  the  eighth  pair  of  nerves  may  have  some 
agency  in  the  production  of  this  disease,  and  is  probably  the 
cause  of  the  double  irritation  of  the  bronchise  and  stomach  which 
sometimes  appears.  II    This  opinion,  revised  by  M.  Breschet,  who 

*  Treatise  on  the  nature  and  treatment  of  chin  cough,  including  a  variety  of 
cases  and  dissections,  by  Robert  Watt,  M.  D.,  Glasgow,  1815. 

t  Traite  de  la  coqueluche,  ou  bronchite  epidemique,  son  diagnostic,  sa  nature,  ei 
son  traitment,  translated  from  the  German  by  E.  L.  Jacques.     Paris,  1821. 

t  Traite  de  la  coqueluche.     Prize  essay.     Paris,  1827. 
.    §  Handbuch.  der  Kinderkrankeiten.    Frankfort,  1821. 

II  System  der  praktische  hielkunde.    Jena,  1818 — 1828. 


ON    THE    DISEASES    OF    INFANTS.  427 

found  in  two  individuals  that  died  of  catarrh  accompanied  with 
a  suffocating  cough,  the  pneumo-gastric  nerves  red  externally 
and  yellow  internally,  has  not  been  confirmed  by  the  indefatiga- 
ble researches  of  M.  Guersent ;  and  I  have,  in  every  instance  of 
death  from  hooping-cough,  dissected  the  pneumo-gastric  nerve, 
without  ever  being  able  to  discover  any  lesion ;  so  that  this  idea 
must  be  considered  as  not  yet  demonstrated. 

Lastly,  Aiithenrieth,  from  the  success  which  followed  his  me- 
thod of  treatment,  is  of  opinion  that  hooping-cough  is  owing  to 
an  accumulation-  of  lymph  towards  the  bronchise,  and  that  this 
cause  can  be  removed  by  causing  exteriorly  the  formation  of 
pustules  which  contain  lymph.* 

The  examination  of  bodies  has  not  exhibited  any  thing  uni- 
form in  this  disease,  except  bronchial  catarrh  in  various  stages 
of  advancement,  almost  always  accompanied  with  a  considerable 
quantity  of  mucosity  accumulated  in  the  bronchice,  which  are 
sometimes  sensibly  dilated,  and  exhibit  a  vivid  red  color.  Among 
the  concomitant  lesions  of  the  catarrh,  there  are  very  often  found 
inflammation  of  the  lymphatic  ganglia  in  the  vicinity  of  the  bron- 
chiae,  and  a  dilatation  of  the  termination  of  the  bronchise,  pointed 
out  for  the  first  time  by  Laennec.  I  once  saw  this  in  a  child  of 
fifteen  months^  and  who  presented  at  the  extremities  of  the  bron- 
chise a  species  of  small  vesicles  filled  with  a  creamy,  inodorous  pus. 
The  unequal  dilatation  of  the  bronchise  has  also  been  met  with 
in  some  infants ;  it  is  the  same  in  emphysema ;  lastly,  this  dis- 
ease is  found  complicated  with  pneumonia,  pleurisy,  pulmonary 
tubercles,  chronic  enteritis,  mesenteritis,  menengitis,  hydrocepha- 
lus ;  but  in  considering  the  variety  and  number  of  these  compli- 
cations, do  we  not  see  also  that  some  are  the  ordinary  result  of 
pulmonary  affections  of  long  duration,  and  other  accidental 
effects  of  peculiar  idiosyncracy  ?  Wherefore,  then,  seek  among 
all  the  complications  of  hooping-cough  for  lesions,  which  will 
give  us  a  proper  idea  of  the  seat  and  nature  of  the  disease,  whilst 
there  exists  one  princpial  lesion  always  constant,  always  identi- 
cal, to  which  it  is  more  natural  to  refer  the  prerogative  of  being 
one  of  the  principal  causes  of  hooping-cough  ?  I  am  sensible 
how  much  the  nature  of  the  discussion  upon  which  we  have 

*  Versuche  Jiur  die  praktische  heilkundc.     Tubingue,  1808. 


428  ON   THE    DISEASES    OF    INFANTS. 

entered  is  calculated  to  lead  us  into  vain  speculations ;  I  will 
hasten  then  to  trace  the  progress  of  the  symptoms  and  the  treat- 
ment of  this  disease. 

All  authors  since  the  time  of  Rosen  have  recognised  different 
periods  in  the  disease,  and  M.  Guersent,  in  his  excellent  article 
Coqueluche,  in  the  Dictionnaire  de  medicine,  has  traced  them 
with  great  care.  The  development  of  this  disease  doubtless  ex- 
hibits several  stages,  but  notwithstanding  the  attention  I  have 
bestowed  on  the  subject,  I  have  found  them  so  variable  with  re- 
spect to  their  duration,  and  even  their  characters,  that  I  believe 
it  to  be  impossible  to  assign  to  them  any  constant  symptoms  or 
limits. 

Hooping-cough  always  commences  with  simple  bronchial 
catarrh ;  and  even  during  its  prevalence  as  an  epidemic,  many 
children  have  nothing  more  than  a  catarrh,  which  terminates  at 
the  end  of  a  few  days  or  weeks  without  ever  exhibiting  the  cha- 
racters of  hooping-cough,  whilst  other  children  living  under  the 
same  atmospheric  influence  have  the  disease  with  all  its  pecu- 
liar traits.  Is  it  that  some  have  a  false  and  others  a  true  hoop- 
ing-cough ?  It  would  be  scarcely  in  place  to  repeat  what  has 
been  said  of  croup  with  regard  to  this  question.  It  is  much 
more  reasonable  to  believe  that  the  disease  has  existed  in  these 
children  in  different  degrees,  and  that  it  varies  in  them  from  a 
slight  to  a  severe  affection.  When  the  cough  increases,  with 
the  irritation  of  the  bronchiss,  the  face  becomes  puffed,  the  eyes 
injected,  the  respiration  accelerated ;  the  expectoration  is  at  first 
thin,  limpid,  and  serous  :  the  cry  and  voice  become  peculiar  in 
their  tone,  easily  recognised  by  experienced  practitioners.  I 
have  often  seen  children  with  the  disease  confined  to  simple 
bronchial  catarrh,  and  continue  for  a  long  time  only  affected 
with  it  in  this  simple  form.  I  remember  particularly  a  little  girl 
at  the  infirmary  of  the  Hospice  des  Enfans  Trouves,  who  had  a 
pecuHar  cough,  accompanied  with  symptoms  of  suffocation  and 
an  abundant  expectoration,  which  lasted  about  forty-eight  hours. 
It  was  thought  that  the  hooping-cough  was  about  to  be  devel- 
oped, to  continue  for  a  greater  or  less  time  ;  nothing  of  this  kind, 
however,  occurred,  and  the  symptoms  disappeared  rapidly  with- 
out any  active  treatment;    and  although  this  child  remained 


ON    THE    DISEASES    OF    INFANTS.  429 

some  time  in  the  infirmary,  there  existed  no  more  symptoms  of 
suffocating  catarrh. 

When  hooping-cough  becomes  severe,  the  chest,  particularly 
about  the  sternum,  is  the  seat  of  considerable  pain ;  the  cough 
returns  in  paroxysms,  with  shorter  intervals  between  them,  in- 
creasinor  more  at  night,  and  is  almost  always  preceded  by  a  mu- 
cous rale,  which  is  more  evident  as  the  paroxysms  approach  each 
other.  In  a  fit  of  coughing,  the  suflEbcation,  pain,  and  strangling 
produce  the  greatest  distress  in  the  patient,  who  seizes  every 
thing  within  its  reach  with  a  spasmodic  effort,  with  violent  at- 
tempts at  inspiration,  accompanied  with  acute  cries  and  smothered 
and  incomplete  wheezings ;  in  the  meanwhile,  the  face  becomes 
purple  and  tumefied,  the  jugular  veins  are  filled  with  blood,  the 
neck  dilates  with  a  painful  effort,  and  the  limbs  are  stiftened  with 
spasm ;  the  child,  alarmed  at  its  own  distress,  sometimes  loses  its 
consciousness,  and  appears,  from  the  momentary  suspension  of 
breathing,  to  be  dying.  Yery  frequently  there  is  no  rale  heard 
during  the  paroxysms  of  coughing,  and  it  is  remarkable  that  the 
more  dry  the  cough  the  more  painful  and  suffocating  it  is ;  it 
becomes  much  less  when  the  mucosities  are  abundant  in  the 
trachea.  All  these  violent  efforts  usually  terminate  in  vomiting, 
by  which  the  child  not  only  throws  up  what  it  had  eaten,  but 
likewise  an  abundance  of  mucosity.  When  the  cough  ceases, 
the  child  recovers  from  its  distress  by  degrees,  remains  exhausted 
for  some  minutes,  and  complains,  if  old  enough,  of  pain  in  the 
forehead  and  sternum ;  its  cry  and  voice  are  feeble ;  but  this 
state  of  fatigue  is  of  short  duration,  for  its  gaiety  soon  returns, 
and  it  enjoys  the  sports  of  its  age  until  prostrated  by  a  new  pa- 
roxysm of  coughing. 

Hooping-cough  continues  for  a  greater  or  less  time  in  the 
acute  state,  such  as  I  have  just  described ;  it  is  often  accompanied 
with  fever,  especially  in  the  commencement,  but  by  degrees  this 
symptom  of  reaction  becomes  less  intense,  or  does  not  appear  at 
all.  This  is  not  the  case,  however,  when  it  is  complicated  with 
pneumonia,  pleurisy,  or  hydrocephalus.  When  hooping-cough 
occurs  in  scrofulous  children,  it  may  hasten  the  disorganization 
which  tubercles  effect,  and  thus  terminate  in  phthisis  of  the 
larynx  or  lungs. 

At  the  end  of  a  few  weeks  or  months,  the  symptoms  diminish 


430  ON   THE    DISEASES    OF    INFANTS. 

in  intensity,  the  expectoration  is  more  abundant,  and  the  muco- 
sity  thicker ;  the  cough  becomes  less  fatiguing,  is  less  intense 
and  less  frequent,  and  finally  disappears  with  the  whole  assem- 
blage of  other  symptoms. 

The  prognosis  of  hooping-cough  is  unfavorable  in  proportion 
to  the  dangerous  nature  of  its  complications  and  the  early  age  of 
the  child.  M.  Guersent  has  correctly  observed  that  in  infants  at 
the  breast  it  is  often  complicated  with  cerebral  congestions,  and 
from  the  first  development  of  this  disease  in  them,  this  complica- 
tion is  quickly  fatal.  We  can  easily  conceive  the  danger  arising 
from  pneumonia,  pleurisy,  softening  of  tubercles,  pneumo-thorax, 
and  other  complications  of  hooping-cough. 

Treatment. — Two  principal  indications  present  themselves  in 
the  treatment  of  this  disease — to  combat  the  inflammation  of  the 
bronchiaB,  and  to  moderate  or  remove  the  nervous  complication. 
It  will  be  necessary,  in  the  beginning  of  the  disease,  to  have  re- 
course to  sanguineous  evacuations,  both  general  and  local,  to  de- 
mulcent drinks,  and  revulsives  to  the  intestinal  tube  ;  in  a  word, 
it  must  be  treated  by  a  purely  antiphlogistic  method,  rigorously 
pursued  during  its  inflammatory  stage  :  as  bronchial  irritations 
will  quickly  produce  in  young  infants  pulmonary  or  cerebral 
congestions,  it  will  be  useful  to  apply  a  few  leeches  to  the  neck, 
ior  lateral  parts  of  the  thorax,  upon  the  slightest  symptoms  being 
perceived  of  irritation  in  these  organs.  This  was  the  practice, 
observes  Dr.  Dewees,  of  Willis,  and  appears  to  have  been  the 
general  practice  of  the  age,  and  particularly  of  Sydenham,  As- 
true,  Home,  and  others.  The  success  of  these  celebrated  practi- 
tioners ought  to  induce  us  to  imitate  their  practice.  I  cannot  be- 
lieve it  to  be  a  natural  practice  to  administer  emetics  at  the  same 
time,  in  order  to  relieve  the  stomach  from  the  mucosity  with 
which  it  is  filled.  If  antimony  and  squills  are  to  be  given,  it 
ought  rather  to  be  as  expectorants  than  in  vomiting  doses ;  as 
half  a  grain  of  kermes,  (sulphuret  of  antimony,)  in  a  two-ounce 
mixture,  for  a  child  of  eight  months  to  a  year  old,  is  sufficient  to 
produce  an  abundant  expectoration.  We  should  remember  that 
very  young  infants  do  not  expectorate,  and  that  it  will  but  fa- 
tigue them  in  vain  to  persevere  in  giving  medicine  of  this  kind. 
The  English  physicians  assert  that  calomel,  given  in  doses  of  a 
few  grains  every  two  or  three  days,  renders  the  progress  of  hooping- 


ON   THE    DISEASES    OF    INFANTS.  431 

cough  more  irregular  and  shorter.  I  can  conceive,  indeed,  without 
partaking  of  their  predilection  for  this  medicine,  that  it  will  accom- 
plish a  good  purpose  in  keeping  the  bowels  open,  and  thus  advan- 
tageously counteract  the  catarrhal  inflammation  of  the  bronchiae. 

When  we  are  satisfied  that  the  first  symptoms  of  inflammation 
are  moderated,  and  that  the  nervous  irritation  of  the  bronchiae  is 
the  cause  of  the  existing  symptoms,  we  should  endeavor  to  re- 
move it,  and  not  remain  inactive,  which  may  be  fatal  to  the  pa- 
tient, under  the  belief  that  the  hooping-cough  must  run  through 
its  course ;  for  it  is  not  more  dangerous  to  arrest  the  progress  of 
this  disease  than  to  stop  an  intermittent  fever,  the  progress  of  the 
one  requiring  as  much  attention  as  that  of  the  other. 

We  ought,  therefore,  to  avail  ourselves  of  narcotic  and  anti- 
spasmodic remedies  at  the  period  of  the  disease — as  a  demulcent 
mixture,  with  a  quarter  or  half  a  grain  of  the  extract  of  opium,  or, 
what  is  still  better,  one  or  two  drachms  of  syrup  of  poppies.  As- 
safoetida,  given  in  injection,  has  succeeded  in  the  hands  of  some 
practitioners,  but  its  eflicacy  is  not  as  yet  sufficiently  derhonstra- 
ted.  Cullen,  observing  the  periodical  return  of  the  cough,  em- 
ployed cinchona,  but  his  example  has  not  been  followed  by 
others.  Some  advantage  might  be  obtained  from  the  use  of  sul- 
phate of  quinine  in  small  doses  ;  yet  it  must  be  observed  that  the 
remission  is  very  irregular,  and  consequently  we  cannot  foresee 
its  return,  and  might  give  it  even  at  the  moment  the  cough  com- 
mences, which,  without  doubt,  would  interfere  with  the  efficacy 
of  the  remedy.  Hyoscyamus,be]ladonna,  and  cicuta  have  not  been 
forgotten  among  the  narcotics  used  for  the  treatment  of  hooping- 
cough.  The  powder  of  belladonna,  or  its  gummy  extract,  in 
doses  of  a  quarter  to  half  a  grain  in  any  vehicle,  will  produce 
good  effects,  but  its  operations  are  very  uncertain.  The  sedative 
used  by  M.  Guersent  with  great  advantage,  is  a  mixture  of  equal 
parts  of  oxyde  of  zinc,  belladonna,  and  cicuta,  commencing  with 
a  quarter  of  a  grain  of  these  substances,  given  three  times  a  day, 
and  increasing  it  according  to  the  effect  experienced  from  its 
use.  He  has  also  used  the  oxyde  of  zinc  with  success  in  the  dose 
of  a  grain  every  hour  in  an  infant  of  six  weeks,  where  he  had  in 
vain  attempted  to  arrest  the  paroxysms  of  coughing.* 

♦  Guersent,  article  Coqueluche,  in  the  Diet,  de  med.,  t.  vi.  p.  20. 


432  ON   THE    DISEASES    OF    INFANTS. 

We  should  also  use  counter  irritants  to  the  skin,  when  the  dis 
ease  exhibits  no  more  sign  of  active  inflammation.  Blisters  be- 
tween the  shoulders,  camphorated  and  ammoniated  frictions  on 
the  arms  or  lateral  parts  of  the  chest,  may  perhaps  be  of  some 
utility.  Without  endeavoring  to  accomplish  the  end  for  which 
Authenrieth  has  advised  frictions  with  his  ointment,  we  may 
nevertheless  use  it  as  a  simple  revulsive ;  the  epigastrium  or  tho- 
rax may  be  rubbed  with  an  ointment  composed  of  one  part  and 
a  half  of  tartar  emetic  to  eight  parts  of  the  lard;  care  must  be 
taken  not  to  rub  the  pustules  already  formed,  for  ulcers  may 
arise  and  cause  fever.  Dr.  Dewees  uses  an  ointment  composed  of 
the  same,  with  the  addition  of  fifteen  drops  of  ol.  lavend.  or  lemon. 

The  state  of  feebleness  in  which  the  child  remains  for  a  long 
time  after  the  hooping-cough  has  disappeared,  requires  the 
greatest  attention  from  the  physician.  Before  using  tonics,  such 
as  the  syrup  or  wine  of  cinchona,  it  will  be  necessary''  to  habitu- 
ate it  gradually  to  nourishment  of  increased  strength,  as  chicken 
water,  veal  or  beef  tea,  animal  jellies,  feculent  vegetables,  and 
only  habituate  it  progressively  to  the  use  of  medicinal  or  other 
wines.  Goats'  milk,  pure  or  diluted,  a  good  nurse,  a  residence 
in  the  country,  particularly  in  the  spring  and  summer,  will  ma- 
terially conduce  to  the  recovery  of  infants  at  the  breast. 

This  is  perhaps  the  proper  place  to  speak  of  nervous  respira- 
tion— such  as  hiccup,  spasm  of  the  glottis,  etc. ;  but  as  we  are 
in  possession  of  no  other  than  very  uncertain  data  upon  these  af- 
fections, I  do  not  think  it  necessary  to  devote  a  chapter  to  the 
consideration  of  a  subject  on  which  I  have  nothing  more  to  say 
than  has  already  been  advanced  a  number  of  times.  It  is,  be- 
sides, to  be  remarked,  that  spasm  of  the  glottis  is  often  but  a 
symptom  of  different  inflammatory  diseases  of  which  I  have  al- 
ready spoken. 

I  will  end  this  account  of  the  history  of  diseases  of  the  thorax 
by  observing  that  the  application  of  the  stethoscope  and  percus- 
sion are  neither  so  useless  in  infantile  diseases  or  so  injurious  to 
them  as  M.  Denis  has  asserted  in  his  work,  (page  336,)  or  as  is 
expressed  by  M.  Guersent  in  the  article  Enfant  in  the  Diet,  de 
med.  We  have  seen  in  this  chapter  that  these  means  may  be 
used  as  a  proper  method  of  investigation  in  the  thoracic  diseases 
of  children. 


ON    THE    DISEASES    OF    INFANTS.  489 

pia  mater  and  tunica  arachnoidea,  at  the  posterior  part  of  the  medulla 
spinalis. 

In  this  case  we  see  how  trifling  were  the  symptoms  which  ac- 
companied the  inflammation,  and  even  the  disorganization  of 
the  cerebrum.  A  few  convulsive  motions  of  the  eyelids  or  of 
the  ball  of  the  eye,  a  slight  muscular  action  in  the  face,  are  often 
the  only  symptoms  of  encephalitis  in  young  infants.  Inflamma- 
tion of  the  stomach  was  here,  perhaps,  one  of  the  predisposing 
causes  of  encephalitis.  This  complication  is  not  so  common  as 
at  a  more  advanced  age.* 

Let  us  endeavor  now  to  ascertain  the  nature  and  probable  seat 
of  the  symptoms  which  it  appears  natural  to  refer  to  the  brain. 

Convulsions. — Cerebral  or  spinal  meningitis  is  most  frequently 
the  cause  of  convulsions.  If  there  exist  cases  where  it  is  diffi- 
cult, on  examining  the  body,  to  discover  traces  of  inflammation 
of  the  meninges,  it  is  because  of  the  extreme  difficulty  of  dis- 
tinguishing their  passive  congestion  from  phlegmasia,  and  also, 
on  the  other  hand,  it  is  easy  to  conceive  that  an  irritation  of  the 
tissue  of  an  organ  may  arise  before  the  inflammation  can  mani- 
fest  itself,  at  least  to  a  sufficient  degree  to  be  evident  to  our  senses. 
Besides,  as  it  is  much  more  common  to  find  convulsions  in  infants 
with  meningitis,  than  to  meet  with  them  without  this  inflamma- 
tion, analogy  might  produce  the  conviction  that  the  convulsions 
of  children,  whatever  be  their  form  or  degree,  whether  known  as 
spasms,  cramps,  twitchings,  etc.,  all  arise  from  cerebral  or  spinal 
meningitis.  This  opinion  has  been  fully  demonstrated  by  M. 
Brachet,  of  Lyons.t 

Tetanus. — I  am  not  in  possession  of  sufficient  facts  to  eluci- 
date the  nature  of  this  disease  ;  it  occurs  much  more  rarely  in 
our  climate  than  in  hot  countries,  where  a  large  number  of  chil- 
dren die  from  it. 

I  am  unable  to  give  any  opinion  on  the  different  views  enter- 
tained by  authors  on  the  nature  of  this  disease,  having  seen  but 
two  cases  of  it  in  young  infants  ;  they  were  both  characterized 
with  rigidity  of  the  vertebral  column  and  of  the  jaw.     I  found, 

*  SablairoUes,  Influence  des  organs  digestifs  des  enfans  sur  le  cerveau.     Paris, 
1827. 
t  Brachet,  Memoire  sur  les  causes  des  convulsions  oktx  Us  enfans.     Paris,  1824. 


490  ON   THE    DISEASES    OF    INFANTS. 

on  dissection,  nothing  more  than  an  effusion  of  a  quantity  of  co- 
agulated blood  in  the  spine.  This  blood  was  effused  between 
the  two  laminae  of  the  tunica  arachnoidea,  and  filled  the  whole 
of  the  medullary  canal,  from  the  medulla  oblongata  to  the  sacral 
region.  Were  the  symptoms  of  tetanus  to  be  ascribed  to  this  hem- 
orrhage of  the  spine  ?     I  am  disposed  to  think  they  were. 

I  shall  not  speak  here  of  delirium,  because  it  can  only  be 
observed  when  the  intellectual  functions  are  developed. 

The  treatment  of  encephalitis  does  not  differ  from  that  of  me- 
ningitis, which  has  already  been  described.  Besides,  encephalitis 
is  almost  always  accompanied  by  meningitis. 


CHAPTER    XT. 

DISEASES    OF    THE    ORGANS    OP    LOCOMOTION. 

In  a  month  or  six  weeks  after  conception,  the  limbs  appear, 
under  the  form  of  small  projections,  slightly  flattened  laterally 
and  inclining  towards  the  trunk.  The  upper  extremities  appear 
first ;  at  two  months,  the  hand  and  forearm  can  be  distinguished ; 
the  leg  and  foot  show  themselves  at  the  third  or  fourth  month. 
When  the  forearm  and  leg  begin  to  appear,  M.  Beclard  observes, 
they  are  smaller  than  the  hand  or  foot ;  and  even  the  thigh  and 
arm  are  smaller  than  the  leg  and  forearm.  The  upper  extremi- 
ties are  distinctly  divided  into  two  parts  at  seven  weeks,  and  the 
lower  at  eight  weeks  ;  the  summits  enlarge  and  divide  into  short 
fingers  and  toes,  which  remain  attached  by  a  soft  substance  until 
the  third  month ;  this  substance  then  gradually  disappears,  be- 
ginning at  the  extremity.  For  a  long  time  the  superior  extremi- 
ties, which  are  the  first  that  are  formed,  continue  the  largest,  but 
about  the  fourth  month  the  superior  and  inferior  extremities  are 
about  equal.* 

Malformations  are  very  numerous  ;  the  limbs  may  be  deficient, 
or  they  may  be  supernumerary  ;  they  may  undergo  an  arrest  in 
their  formation  ;  may  become  divided,  broken,  or  dislocated  du- 
ring intra-uterine  life. 

*  Dissertation  Inaugurale,  p.  60. 


ON   THE    DISEASES    OF    INFANTS.  491 

Haller  has  given  a  number  of  instances  of  absence  or  plurality 
of  limbs,  or  of  one  or  more  parts  of  the  same  member.  He  has 
also  recorded  several  cases  of  supernumerary  limbs,  implanted 
in  different  parts  of  the  body.*  Since  his  time  the  records  of 
science  have  contained  a  great  number  of  analogous  facts,  the 
details  of  which  cannot  here  be  given  without  exceeding  our 
bounds,  and,  indeed,  they  do  not  comport  with  the  nature  of  this 
treatise  ;  1  must,  therefore,  refer  to  works  specially  devoted  to 
pathological  anatomy,  for  further  information  on  this  subject,  and 
will  confine  myself  to  the  consideration  of  solutions  of  conti- 
nuity, fractures,  and  dislocations  which  occur  during  the  con- 
tinuance of  the  child  within  the  womb,  or  which  may  take  place 
at  birth. 

It  would  appear  as  if  gangrene  might  aifect  the  limbs  of  a 
foetus  and  produce  a  separation  more  or  less  complete,  and  the 
infant  be  born  with  a  limb  divided,  with  the  trace  of  a  cicatrix 
on  the  stump.  A  child  was  born  at  the  Maternite  of  Paris  with 
but  one  arm ;  the  surface  of  the  stump  was  cicatrized  and  a 
bony  cylinder  found  implanted  in  the  placenta,  which  probably 
was  the  other  portion  of  the  amputated  humerus.  Chaussier 
was  of  opinion  that  this  member  had  been  separated  by  a  species  of 
sphacelus.t  On  the  29th  of  December,  1824,  Dr.  Atkinson  was 
called  to  attend  a  young  woman  aged  twenty  years,  who  had 
been  married  in  the  month  of  April  preceding.  I  found,  says 
this  physician,  the  membranes  still  entire ;  at  eleven  o'clock  they 
broke,  and  half  an  hour  after  the  child  was  born.  I  immediately 
perceived  that  the  left  foot  was  wanting,  and  that  it  had  been 
separated  from  the  leg  a  little  below  the  calf  The  amputated 
surface  was  cicatrized  except  at  its  centre,  doubtless  from  the  pro- 
jection of  the  bone.  The  child  was  living,  but  expired  in  about 
twenty  minutes.  After  the  labor  had  terminated,  upon  examin- 
ing the  genital  organs,  I  found  the  foot  in  the  vagina,  and  im- 
mediately removed  it.  The  section  was  also  cicatrized,  except 
at  the  point  where  the  bone  projected.  There  existed  nothing 
to  indicate  that  any  hemorrhage  had  been  produced  by  the  am- 
putation. This  foot,  which  was  much  smaller  than  the  right, 
exhibited  no  mark  of  putrefaction,  and,  on  comparing  it  with  the 

*  Opera  minora — De  monstris,  {partes  dejicientes,)  t.  iii. 
t  Discourse  delivered  in  1813,  at  the  distribution  of  the  prizes  at  the  Maternity. 


492 


ON   THE    DISEASES    OF    INFANTS. 


Other,  I  judged  that  it  had  been  separated  about  two  months. 
The  mother,  during  her  pregnancy,  had  not  experienced  any- 
thing that  could  explain  this  lesion,  nor  of  the  time  at  which  it 
occurred.* 

The  limbs  of  a  foetus  may  sometimes  be  dislocated.  Chaus- 
sier  has  observed  in  a  foBtus  both  thighs,  both  knees,  both  feet, 
and  three  fingers  of  the  left  hand,  in  this  condition.  Professor 
Dupuytren  has  recently  pubhshed  a  very  interesting  paper  upon 
the  spontaneous  dislocation  of  the  os  femoris,  which,  in  the 
greatest  number  of  cases,  existed  on  both  sides  at  once,  although 
in  some  individuals  it  may  occur  on  one  side  only.  "  In  twenty 
cases  of  this  affection  which  I  have  seen,"  says  M.  Dupuytren, 
"  the  luxation  existed  on  one  side  only,  in  two  or  three  individ- 
uals. I  have  now  under  my  care  a  young  infant  who  has  a 
dislocation  only  on  one  side,  and  what  renders  this  case  the  more 
curious  is,  that  this  child  had  a  sister  affected  in  the  same  man- 
ner, and  which,  like  the  other,  existed  on  the  right  side."t  The 
dislocation  is  not  usually  perceived  at  the  time  of  birth  ;  but  it  is 
easily  distinguished  as  the  child  advances  in  age.  It  becomes 
apparent,  observes  M.  Dupuytren,  when  the  pelvis  acquires  a 
greater  width,  and  the  child  uses  longer  and  more  fatiguing  ex- 
ercise. It  is  then  that  the  want  of  support  of  the  upper  part  of 
the  body  on  the  pelvis,  and  its  inclination  forward,  the  hollow- 
ness  of  the  back,  projection  of  the  abdomen,  arched  movements 
of  the  extremities,  defect  in  the  flexibility  of  the  head  of  the  fe- 
mur, its  alternate  elevation  and  depression  in  the  external  iliac 
fossa,  etc.,  begin  to  be  very  evident. 

This  dislocation  is  generally  upward  and  outward,  and  the 
head  of  the  bone  rests  in  the  external  iliac  fossa.  According  to 
M.  Dupuytren,  this  displacement  appears  to  arise  from  the  habit- 
ual position  of  the  legs  of  the  foetus  in  the  uterus.  The  thighs 
are  closely  flexed  on  the  abdomen,  and  the  head  of  the  bones  are 
continually  pressing  against  the  posterior  and  inferior  part  of  the 
capsular  ligament;  this  unceasing  pressure,  although  without 
any  effect  in  well-formed  individuals,  may  produce  a  dislocation 
in  others  whose  tissues  are  less  resisting.     With  this  fact  before 

♦  London  Medical  and  Physical  Journal,  J^ly>  1825. 
t  Repertoire  general  d'anatomie,  tome  v,,  page  110. 


ON   THE    DISEASES    OF    INFANTS.  49^ 

US,  we  can  understand  how  it  happens  that  the  posterior  and  in- 
ferior part  of  the  capsular  Ugament  yields  to  the  pressure,  and  al- 
lows the  head  of  the  bone  to  pass,  thus  producing  a  luxation ; 
and  its  displacement  upward  and  outward  is  explained  by  the 
action  of  the  most  powerful  muscles  surrounding  the  joint,  tend- 
ing constantly  to  cause  the  head  of  the  bone  to  pass  in  that  di- 
rection after  its  passage  from  the  acetablum.* 

The  treatment  ought  to  be  commenced  as  advised  by  M.  Du- 
puytren,  by  rest  and  the  use  of  means  to  strengthen  the  soft  parts 
surrounding  the  articulation,  and  to  prevent  the  passage  of  the 
head  of  the  bone  into  the  iliac  fossa.  It  is  very  difficult  to  use 
these  means  to  children  at  the  breast ;  but  we  may  at  least  ar- 
rest the  too  rapid  progress  of  the  disease  by  directing  that  the 
child  be  not  made  to  stand,  as  is  often  done,  to  enable  it,  as  it  is 
said,  to  acquire  strength  ;  for  we  can  easily  conceive  that  the  ele- 
vation of  the  head  of  the  fernur  into  the  iliac  fossa  may  be  facili- 
tated by  the  weight  of  the  body.  I  cannot  here  detail  all  the  im- 
portant doctrines  contained  in  this  treatise,  but  must  be  contented 
to  refer  the  reader  to  it  for  perusal.f 

Besides  luxations,  the  bones  of  the  foBtus  may  be  affected  with 
solutions  of  continuity,  either  from  an  arrest  in  the  development, 
or  from  a  fracture  analogous  to  what  is  seen  in  adults  ;  the  fol- 
lowing case  will  demonstrate  the  possibility  of  solutions  of  con- 
tinuity from  an  arrest  of  development. 

CASE  LXXXV. — A  child,  aged  two  months,  died  at  the  Hos- 
pice des  Enfans  Trouves  on  the  4th  of  June,  1826,  of  acute  pneumo- 
nia. On  examining  the  body,  I  perceived  that  the  humerus  was 
moveable  at  the  middle,  where  there  existed  a  species  of  false  articu- 
lation ;  a  close  examination  of  the  part  enabled  me  to  ascertain  that 
there  was  a  solution  of  continuity  at  the  centre  of  the  bone,  to  the 
extent  of  about  four  lines ;  this  space  was  filled  with  a  cartilaginous 
substance  of  some  thickness,  the  exterior  of  which  was  in  contact 
with  the  extremities  of  the  broken  bones,  in  the  same  manner  as  the 

♦  Memoire  sur  un  deplacement  originel  and  congenital  de  la  tete  des  femurs,  par 
M.  Dupuytren. 

t  The  cases  and  plates  published  by  M.  Cruveilhier  may  be  consulted  with  advan- 
tage. They  go  to  prove,  according  to  the  opinion  of  M.  Dupuytren,  that  this  deformity, 
as  well  as  that  of  club-foot,  depends  on  the  situation  of  the  limbs  of  the  foetus  in  utero. 
(See  Anatomic  pathologique  du  corps  humain,  etc.,  2d  number,  pi.  2.) 


494  ON   THE    DISEASES    OF    INFANTS. 

epiphysis  of  the  bones.  This  humerus  was  not  longer  than  the  one 
on  the  opposite  side  ;  the  space  of  which  I  spoke,  therefore,  was  not 
formed  by  a  substance  deposited  between  the  two  fragments  of  bone, 
but  was  the  rudiments  of  the  bony  cartilages,  which,  by  a  singular 
anomaly,  had  not  become  ossified. 

It  is  not  improbable  that  children  born  with  a  number  of  frac- 
tures, of  which  Chaussier  has  given  instances,  may  have  been  in 
a  condition  similar  to  this  infant.  I  have  seen  a  striking  anal- 
ogy between  the  engraved  representation  of  the  solutions  of  con- 
tinuity in  the  bones  of  the  skeleton,  in  the  work  of  this  learned 
anatomist,  and  that  which  I  liave  recorded.  It  would  seem  as  if 
the  continuity  of  the  osseous  fibres  had  been  interrupted  by  an 
arrest  of  development,  and  the  part  appeared  as  though  filled  by 
a  number  of  cartilaginous  intersections.  All  these  fragments  were 
applied  to  each  other  by  points,  the  reciprocal  surfaces  of  which 
were  rough  like  the  corresponding  surface  of  the  sphenoid  and 
the  basilary  portion  of  the  occipital  bone  in  young  children. 

Besides  this  species  of  solution  of  continuity,  there  also  occurs 
in  the  foetus  real  fractures,  which,  at  the  period  of  birth,  exhibit 
the  beginning  of  consolidation.  M.  Devergie  reported  at  the  sit- 
ting of  the  Academic  Royale  de  Medicine  on  the  4th  of  February 
1825,  the  case  of  a  woman  who,  in  the  sixth  month  of  her  preg- 
nancy, struck  her  abdomen  violently  against  the  corner  of  a  ta- 
ble, falling  from  a  high  chair.  The  pain  was  extremely  severe 
and  continued  a  long  time  without  any  thing  affording  relief.  It 
suddenly  disappeared,  and  at  the  usual  end  of  the  period  of  gesta- 
tion she  was  delivered  of  a  healthy,  vigorous  child,  having  a  large 
tumor  on  the  left  clavicular  region.  The  child  died  on  the 
eighth  day  after  birth,  and  on  the  examination  of  the  body  there 
was  found  a  fracture  of  the  clavicle,  the  fragments  of  which  had 
united  by  a  large  and  firm  callus,  forming  the  tumor  above  men- 
tioned. Do  not  the  circumstances  of  this  case  produce  the  im- 
pression that  there  was  a  connection  between  the  violent  blow 
received  by  the  mother  two  or  three  weeks  before  her  confine- 
ment, and  the  consolidated  fracture  of  the  clavicle  ? 

The  following  case,  taken  from  a  German  journal,  and  copied 
in  the  Archives  generales  de  medicine  for  March,  1828,  is  anal- 
ogous to  the  preceding : 


ON   THE   DISEASES    OP   INFANTS.  495 

A  young  woman,  aged  twenty-five  years,  of  a  strong  constitu- 
tion, in  the  sixth  month  of  her  pregnancy,  fell  on  the  abdomen ; 
she  immediately  felt  the  child  move  with  great  force  ;  these 
movements  continued  for  some  time.  The  period  of  her  confine- 
ment arrived,  and  she  was  delivered  without  accident  of  a  very 
thin  and  feeble  child,  giving  but  few  signs  of  life,  and  exhibiting 
on  the  right  leg  a  transverse  wound,  nine  lines  in  length.  This 
wound,  the  lips  of  which  were  pale  and  flaccid,  extended  from 
one  malleolus  to  the  other,  and  involved  both  the  skin  and  subja.- 
cent  muscles,  and  was  accompanied  with  a  fracture  of  the  tibia. 
The  body  of  this  bone  was  entirely  separated  from  its  lower  epi- 
physis ;  it  projected  from  the  wound,  and  was  without  its  perios- 
teum, and  exhibited  a  very  unhealthy  appearance.  The  re- 
duction was  attempted  in  vain.  It  was  abandoned  on  acount 
of  the  edges  of  the  wound  becoming  sphacelated,  and  necrosis 
having  made  some  progress.  The  sphacelus  extended  rap- 
idly, and  the  child  died  on  the  thirteenth  day.  Dr.  Cams,  to 
whom  we  are  indebted  for  this  case,  regarded  it  as  a  new  proof 
that  a  child  may  endure  a  disease  for  a  long  time  in  the  uterus, 
which  may,  after  birth,  quickly  becoroe  mortal. 

It  is  not  unusual  to  see  fractures  occurring  during  labor  or  af- 
ter birth  ;  they  may  be  known  by  the  same  signs  which  they  ex- 
hibit in  adults,  and  require  the  same  treatment  to  preserve  them 
in  a  proper  position  while  uniting. 

Deformities  of  the  joints  are  not  unfrequently  observed  }  the 
twisting  of  the  feet  or  hands  in  a  direction  opposite  to  what  is  na- 
tural, is  one  which  often  occurs.  This  distortion  takes  place 
principally  in  the  ankle  or  wrist,  which  are  at  this  period  still 
cartilaginous.  It  has  been  the  custom  to  suffer  the  child  to  con- 
tinue with  this  deformity  until  a  more  advanced  age,  when  meas- 
ures are  taken  for  its  relief;  but  would  it  not  be  much  better  to 
attempt  at  an  early  period  the  removal  of  this  distortion,  by  gen- 
tle compression,  which,  slowly  affecting  the  cartilaginous  parts, 
is  more  likely  to  be  effectual  than  when  these  parts  have  under- 
gone the  processes  of  ossification  ? 

Such  are  the  general  details  which  I  have  to  offer  on  the  sub- 
ject of  fractures  and  dislocations  of  the  limbs.  The  muscles  are 
rarely  affected  with  diseases,  in  young  infants,  worthy  of  the  atten- 
tion of  the  physician  ;  in  a  state  of  health,  the  muscles  of  a  child 


496  ON   THE    DISEASES    OF    INFANTS. 

at  birth  are  of  a  rose  color  ;  they  are  of  a  lighter  red  than  those 
of  an  adult ;  their  consistence  is  firm,  and  the  direction  of  their 
fibres  is  analogous  to  the  general  form  and  function  of  the  partic- 
ular muscle.  Their  varieties  of  aspect  are  :  1st,  extreme  pale- 
ness :  2dly,  sanguineous  congestion.  I  have  several  times  found 
ecchymoses  in  the  muscles  ;  and  it  is  not  unusual  to  meet  with 
several  small  petechial  spots,  varying  considerably  in  their  form 
and  number  ;  3dly,  a  yellow  color ;  I  have  seen  this  in  one  in- 
stance of  jaundice. 


CHAPTER  XII. 

DISEASES    OF    THE    ORGANS    OF    GENERATION. 

I  HAVE  little  to  say  with  respect  to  these  organs.  Their  mal- 
formations, as  they  occur  in  male  children,  have  been  already  in 
part  described,  in  the  article  on  the  diseases  of  the  urinary  pas- 
sages. As  to  those  occurring  in  females,  they  produce  no  mor- 
bid symptoms  until  the  period  of  puberty,  when  the  genital 
functions  are  developed,  and  the  catamenia  appear. 

The  testicles  are  sometimes  found  at  the  abdominal  ring,  or 
they  may  to  a  greater  or  less  degree  have  passed  it,  at  the  time 
of  birth ;  their  continuance  at  this  place  sometimes  gives  rise  to 
inflammatory  affections,  having  a  resemblance  to  peritonitis: 
they  will  require  the  application  of  emollient  cataplasms,  and 
the  use  of  simple  or  mucilaginous  bathing.  As  these  organs 
descend,  they  become  enveloped  in  the  tunica  vaginalis.  A 
dropsy  of  the  spermatic  cord  may  be  mistaken  for  a  testicle  at 
the  abdominal  ring;  this  affection  consists  of  small  globular 
cysts  in  the  substance  of  the  cord.  When  the  peritoneal  mem- 
brane, which  descends  with  the  testicle  in  order  to  form  the  tu- 
nica vaginalis,  is  not  immediately  closed  above,  a  quantity  of 
serosity  may  accumulate  in  the  sac.  and  thus  form  congenital 
hydrocele,  which  may  be  recognised  by  its  round  shape,  fluctua- 
tion, and  transparency,  but  more  particularly  by  the  facility  with 


ON   THE    DISEASES    OF    INFANTS.  497 

which  the  fluid  passes  into  the  abdomen.  Another  aqiaeous  tu- 
mor of  the  scrotum,  formed  by  a  serous  infiltration  of  tlie  cellular 
tissue,  has  been  confounded  with  this  species  of  hydrocele :  it  is 
frequently  observed  in  induration  or  cedema  of  the  cellelur  tis- 
sue. For  the  treatment  of  the  first  mentioned  hydrocele,  it  will 
be  necessary  to  use  compression  on  the  tumor,  in  order  to  cause 
the  fluid  to  flow  into  the  abdomen,  and  to  maintain  a  moderate 
pressure  by  means  of  an  appropriate  bandage.  With  respect  to 
infiltration  of  the  scrotum,  the  best  applications  are  refrigerants, 
made  either  with  simple  or  vegeto-mineral  water. 

The  testicles  of  an  infant  at  birth  are  of  a  pale  rose  color ; 
their  consistence  is  firm,  and  their  filamentous  texture  can  easily 
be  distinguished.  I  have  sometimes  found  them  ecchymosed 
and  yellow  in  young  subjects  that  had  been  affected  with  jaun- 
dice. 

The  uterus  is  small  in  size,  and  its  central  cavity  is  also  very 
narrow.  The  sides,  however,  which  are  usually  covered  with 
a  mucous  internal  surface,  are  not  absolutely  in  contact.  In 
two  instances  I  have  seen  blood  effiised  and  clotted  in  the  cavity 
of  the  uterus  in  two  children  that  died  a  few  days  after  birth.* 
The  vagina  is  usually  very  much  developed  ;  it  presents  a  large 
elongated  cavity,  covered  with  a  mucous  membrane,  the  secre- 
tion from  which  is  very  abundant,  for  there  is  always  found  in 
this  part,  in  young  infants,  a  large  quantity  of  white,  adherent 
mucosity.  This  secretion,  which  might  be  considered  as  the 
effect  of  a  diseased  condition  of  the  vagina,  such  as  gonorrhcsa 
communicated  by  the  mother  to  the  child,  exists  in  almost  all 
female  infants,  and  appears  to  be  a  necessary  secretion,  judging 
from  the  abundance  of  the  discharge. 

*  It  is  not  unusual  to  observe  red  and  fluid  blood  flow  continually  from  the  vulva 
for  some  days  or  weeks  after  birth.  From  the  observations  of  Dr.  Ollivier,  of  Angers, 
this  discharge,  which  is  somewhat  like  the  catamenia  in  adult  females,  continues  some- 
times a  week,  fifteen  days,  or  more,  without  any  inconvenience  being  experienced  by 
the  child.  It  ceases  of  itself,  and  requires  no  other  care  than  is  usually  necessary  for 
the  infant.  This  sanguineous  discharge  is  unaccompanied  by  redness,  swelhng,  or  any 
other  symptom  of  irritation  in  the  external  parts  of  generation.  The  child  has  no  diffi- 
culty in  urinating,  the  alvine  evacuations  are  neither  more  nor  less  frequent  than  in  the 
normal  state,  and  the  general  health  of  the  child  undergoes  no  derangement.  It  would 
seem  as  if  nature  had  anticipated,  in  some  sort,  the  establishment  of  the  function  which 
is  developed  and  regulated  at  a  later  period  c£  life. 

63 


498  ON    THE    DISEASES    OF    INFANTS. 

The  clitoris  is  large,  and  is  sometimes  even  of  so  great  a  size 
as  to  be  taken  for  a  penis,  and  thus  confounding  the  sex  at  the 
time  of  birth.  The  external  labia  are  very  prominent ;  they 
become  infiltrated,  tumefied,  and  inflamed,  with  the  greatest 
facility,  when  constantly  covered  with  the  excretions.* 

*  Gangrene  of  the  vulva. — In  the  article  on  gangrene  of  the  mouth,  (page  192,)  it 
was  observed  that  gangrenous  inflammation  may  be  developed  in  the  external  and 
internal  parts  of  generation,  with  characters  closely  resembling  those  which  are  seen  in 
the  parietes  of  the  buccal  cavity.  The  analogous  structure  of  these  parts  will  account 
for  the  analogy  of  their  diseases.  Gangrene  of  the  vulva  has  been  noticed  by  Dr.  OUi- 
vier,  of  Angers,  under  circumstances  similar  to  those  which  have  been  pointed  out  as 
coincident  with  gangrene  of  the  mouth,  or  as  preceding  and  favoring  its  development ; 
as  certain  cutaneous  phlcgmasiae,  variola,  or  measles.  This  disease  is  rare  in  young 
infants,  and  will  sometimes  occur  in  such  a  manner  as  to  render  its  diagnosis  obscure. 

The  child  of  Madame ,  aged  twenty-one  months,  of  a  vigorous  and  robust  con- 
stitution, had  enjoyed  the  best  health,  but  was  observed  to  carry  her  hand,  from  time  to 
time,  to  the  thighs,  as  if  she  experienced  a  slight  inconvenience  at  the  orifice  of  the 
vulva.  The  child,  however,  retained  her  liveliness  and  appetite.  Her  little  brother 
had  been  affected  with  measles,  which  had  passed  through  its  stages  without  any  seri- 
ous consequences.  The  distress  experienced  by  this  child  decided  us  to  examine  the 
condition  of  the  affected  part,  when  there  was  found  on  the  internal  surface  of  the 
right  labium  a  round  superficial  ulcer,  gray  at  the  bottom,  and  surrounded  by  a  bright 
red  circle.  On  the  following  day  measles  appeared,  when  the  ulcer,  which  had  the 
appearance  of  an  aptha,  rapidly  increased  during  the  course  of  the  two  succeeding 
days ;  several  others  precisely  similar  showed  themselves  on  the  internal  surface  of  the 
left  labium,  and  around  the  vulva.  Their  sinuous  borders,  their  grayish  aspect,  and  the 
absence  of  any  odor  or  foetid  discharge,  imparted  to  these  ulcers  a  character  very  closely 
resembling  a  primitive  venereal  affection.  Topical  emollient  applications  of  every  kind 
produced  no  arrest  in  the  progress  of  this  inflammation,  while  the  dryness  of  the  dis- 
eased surfaces,  the  hollow  excavations  extending  through  the  substance  of  the  labium 
first  affected,  and  the  gangrenous  odor  now  apparent,  removed  all  doubts  as  to  the  na- 
ture of  this  affection.  In  the  space  of  twenty- four  hours,  the  whole  of  the  vulva  was 
converted  into  a  black  eschar,  surrounded  by  a  red  livid  circle,  and  its  cedematouS 
condition  gave  a  dry  and  shining  appearance  to  the  skin.  The  measles  disappeared  at 
the  end  of  two  days. 

From  the  first  appearance  of  this  gangrenous  inflammation,  cerebral  disturbance 
was  very  evident,  and  there  existed  at  the  same  time  an  intense  fever ;  while  the  rest- 
lessness, cries,  convulsive  movements,  all  announced  that  the  progress  of  the  disor- 
ganization was  accompanied  with  great  pain.  There  were,  however,  no  alteration  of 
the  features ;  the  abdomen  was  soft  and  without  pain  on  pressure,  and  the  stools  pro- 
cured by  injections  were  of  a  soft  consistence ;  urine  limpid  and  small  in  quantity. 
The  means  employed  in  the  treatment,  until  the  termination  of  the  disease,  were  acid- 
ulated drinks,  injection  of  sulphate  of  quinine,  warm  baths,  lotions,  and  injections  of 
chloride  of  lime  and  of  soda,  and  pledgets  of  lint  saturated  with  a  similar  solution. 
This  treatment  was  unsuccessful,  and  the  child  died,  after  unheard  of  sufferings,  on  the 
twelfth  day. 


ON   THE    DISEASES    OF    INFANTS.  499 

The  breasts  of  young  infants  are  often  the  seat  of  a  swelling 
caused  by  the  accumulation  of  a  milky  fluid,  the  quantity  of 
which  is  often  so  great  as  to  be  thrown  out  with  considerable 
force  when  the  breasts  are  pressed.  This  turgescence,  the  cause 
of  which  it  is  difficult  to  explain,  gives  rise  in  some  cases  to  in- 
flammation, often  followed  by  an  abscess.  This  fluid  is  really 
secreted  by  the  maxillary  gland,  which  is  often  more  completely 
developed  than  the  salivary  gland ;  but  this  development,  or 
rather  the  turgescence,  is  but  transitory. 


CHAPTER  XIII. 

DISEASES    OF    THE    LYMPHATIC    SYSTEM. 

Diseases  of  the  lymphatic  system  are  not  so  common  in  the 
first  eight  or  ten  months  as  they  are  after  that  period.  I  will 
not,  therefore,  stop  to  describe  them,  but  will  simply  remark  that 

The  insidious  progress  of  this  disease  in  the  early  period  of  its  existence,  without 
doubt,  prevented  the  employment  of  stimulating  topical  applications.  In  cases  of  this 
kind,  the  ulcerations  ought  to  be  cauterized,  and  local  measures  freely  used,  in  order, 
if  possible,  to  prevent  the  extension  of  the  gangrene.  The  general  phenomena  are  here 
different  from  those  accompanying  gangrene  of  the  mouth ;  instead  of  an  extreme  fee- 
bleness of  the  pulse,  discoloration  of  the  skin,  hiccup,  tympanitis,  and  diarrhoea,  the 
child  continued  tt  have  a  rosy  hue  of  the  skin,  a  frequent  pulse,  soft  abdomen,  and  a 
firm  and  plump  state  of  the  muscles ;  a  difference  resulting,  in  all  probability,  from  the 
different  seat  of  the  affection.  In  gangrene  of  the  mouth,  all  the  gaseous  products 
of  the  local  disorganization  are  exhaled  at  the  orifice  of  the  respiratory  passages,  and 
perhaps  this  pulmonary  absorption  of  the  putrid  emanations  of  the  gangrenous  part  may 
be  the  cause  of  the  symptoms  of  debility  accompanying  this  disease.  Indeed,  all  the 
phenomena  appear  which  arise  from  the  injection  of  putrid  ir>fAters  into  the  veins.  In 
gangrene  of  the  vulva,  nothing  of  this  kind  is  to  be  seen;  bdt  there  are  present  a  con- 
stant febrile  action,  cries,  and  restlessness  ;  the  intensity  of  which  increases  with  the 
progress  of  the  disorder  ;  the  disorganized  part  being  isolated,  and  not  in  the  vicinity 
of  the  opening  to  the  respiratory  organs,  the  inspired  air  is  not  charged  with  deleterious 
principles. 

Without  doubt,  the  analogy  here  attempted  to  be  estabUshed  between  these  two  dis- 
eases might  be  disputed,  on  the  ground  of  the  different  state  exhibited  by  a  child  in 
these  affections ;  but  whatever  opinion  be  adopted,  it  seems  to  us  rational  to  attribute 
the  greater  rapidity  of  the  approach  of  death  in  the  one  case  to  the  particular  seat  of  the 
local  affection,  which  thus  contributes  directly  to  vitiate  the  blood,  through  the  medium 
of  respiration. 


500  ON   THE    DISEASES    OF    INFANTS. 

the  lymphatic  glands  of  the  mesentery,  which  so  easily  become 
affected  with  chronic  inflammation,  and  even  with  tuberculous 
disorganization,  in  children  above  the  age  of  a  year,  affected  with 
chronic  inflammation  of  the  intestines,  do  not  in  very  young  in- 
fants become  the  seat  of  phlegmasias  ;  but  the  only  alteration 
observed  is  a  slight  tumefaction  :  and  when  the  gland  is  cut,  it 
is  found  to  be  a  little  more  condensed  than  natural,  and  of  a  rose 
or  even  deep  red  color.  The  changes  which  age  effects  in  the 
nutrition  and  texture  of  these  organs  dispose  them  particularly  to 
chronic  phlegmasia,  known  under  the  name  of  tubes  mesenterica. 
It  would  not  therefore  be  proper  to  place  this  disease  among  those 
which  are  peculiar  to  infants  at  the  breast.  I  do  not  say  that 
they  are  at  this  period  of  life  exempt  from  it,  but  only  remark 
that  it  is  of  very  rare  occurrence.  The  lymphatic  ganglia  of  the 
neck  and  those  surrounding  the  bronchial  divisions  and  root  of 
the  lungs  are,  in  young  infants,  much  more  frequently  inflamed 
or  enlarged  than  those  of  the  mesentery.  The  mesenteric  gan- 
glia are  but  slightly  developed  at  this  early  period  of  life ;  but 
they  increase  consideral5ly  in  the  course  of  a  year  ;  and  it  is  to 
be  observed  that  their  diseases  and  alterations  become  more  fre- 
quent in  proportion  as  their  development  acquires  a  marked  pre- 
dominance in  the  system. 


CHAPTER  XIV. 

DISEASES   OF    THE    EYES. 

Art.  1. — Development  and  Congenital  Malformation. 

The  eyes  very  early  exhibit  the  projections  which  correspond 
with  the  form  of  this  organ,  but  they  are  not  organized  in  a  man- 
ner that  will  enable  them  to  perform  the  function  of  vision  until 
towards  the  termination  of  pregnancy  ;  and  they  undergo  suc- 
cessively the  changes  which  insensibly  conduct  them  to  perfect 
organization.  The  eyelids  are  joined  until  the  seventh  month  ; 
and  at  first  the  tunica  sclerotica  is  very  thin  and  transparent. 


ON   THE    DISEASES    OF    INFANTS.  501 

The  cornea,  which  also  appears  soon,  is  at  first  soft  and  opaque, 
and  does  not  exhibit  the  solidity  and  transparency  which  belong 
to  it  until  about  six  months.  At  the  commencement,  it  is  in 
contact  with  the  anterior  surface  of  the  crystalline  lens,  from 
which  it  is  only  separated  when  the  aqueous  humor  is  secreted. 
The  iris  is  closed,  until  about  the  seventh  month,  by  the  pupillary 
membrane,  which  then  separates  in  the  middle  and  retracts  to- 
wards the  circumference,  from  the  disposition  of  its  vessels ; 
their  situation  is  well  described  by  M.  Cloquet.  At  the  time  the 
pupil  opens,  the  aqueous  humor  which  was  situated  behind  the 
iris  interposes  itself  between  the  cornea  and  the  iris,  and  thus 
forms  the  space  which  constitutes  the  anterior  chamber.  The 
vitreous  humor,  which  at  first  is  red,  gradually  loses  this  hue, 
and  assumes  its  proper  transparency.  The  crystalline  lens, 
consisting  originally  of  a  fluid,  enclosed  in  a  sort  of  thin  cyst, 
thickens  by  degrees,  preserving  still  its  transparency,  and  takes 
a  lenticular  form. 

The  continuance  of  the  closure  of  the  eyelids  constitutes  a 
malformation  which  it  is  necessary  to  relieve  immediately,  by 
dividing  them  along  the  line  where  the  borders  of  the  eyelids 
are  in  contact. 

Congenital  cataract  and  imperforation  of  the  iris  require  sur- 
gical operations,  which  it  is  safer  to  defer  to  a  later  period  of  life. 
For  the  further  consideration  of  this  subject,  I  must  refer  to  the 
various  works  devoted  to  surgical  operations,  where  will  also  be 
found,  in  detail,  descriptions  of  congenital  cataract. 

Malformations  of  the  globe  of  the  eye,  its  greater  or  less  pro- 
jection, its  minuteness,  compression,  union  with  that  on  the  op- 
posite side,  or  its  blending  into  one  eye  on  the  median  line,  an 
anomaly  known  by  the  name  of  cyclopia  or  monopsia,  are  usually 
the  result  of  malformation  of  the  orbits,  which  are  found  com- 
pressed, deformed,  or  united  into  one,  with  malformations  of  the 
bones  of  the  cranium  or  nasal  fosssB. 

At  the  time  of  birth,  all  the  parts  constituting  the  eye  are  sufli- 
ciently  perfect  for  the  purpose  of  vision,  but  the  imperfection  of 
this  sense  undoubtedly  arises  from  the  imperfect  organization  of 
the  brain.  As  the  latter  becomes  more  completely  organized, 
the  sight  improves ;  the  axis  of  the  eyes,  at  first  indeterminate,  is 
fixed  on  surrounding  objects,  but  the  attention  of  the  child  is 


502  ON   THE    DISEASES   OF   INFANTS. 

more  especially  directed  to  those  of  a  brilliant  nature ;  and  we 
should  consequently  avoid  placing  the  light  in  such  a  situation 
as  will  cause  its  rays  to  strike  the  eyes  obliquely,  and  thus  force 
the  child  to  make  the  axis  of  vision  to  depart  from  its  natural 
direction.  The  habit  acquired  at  this  time  may  continue  during 
he  whole  life,  and  produce  strabismus. 

Art.  2. — Ophthalmia  of  Infants. 

It  is  sometimes  very  difficult  to  account  for  ophthalmia  in  in- 
fants ;  yet  the  length  and  difficulty  of  the  labor,  and  the  conse- 
quent compression  of  the  head,  may  be  regarded  as  a  cause  of 
this  affection.  Mothers  who  have  gonorrhoea  may  communicate 
purulent  ophthalmia  to  their  children  ;  yet  as  there  are  numbers 
of  children  that  have  ophthalmia,  born  of  mothers  who  have  not 
been  affected  with  any  kind  of  syphilitic  disease,  gonorrhoea 
ought  not  to  be  considered  as  its  sole  cause.  It  would  seem  that 
the  accumulation  of  a  number  of  children  in  a  hospital  disposes 
them  to  this  disease,  for  it  always  prevails  to  a  greater  extent 
among  children  in  hospitals  than  in  large  cities.  Badly  shel- 
tered habitations,  an  atmosphere  filled  with  smoke,  little  attention 
bestowed  on  the  child  in  neglecting  to  wash  the  eyes  upon  the 
appearance  of  any  redness  in  them,  are  evident  causes  of  the 
development  of  the  disease.  Dr.  Heurteloup  has  truly  observed, 
that  the  frequency  of  this  disease  in  the  Hospice  des  Enfans 
Trouves  may  arise  from  the  number  of  children  crowded  in 
badly-aired  wards.* 

It  appears  in  two  distinct  stages :  once  developed,  it  produces 
a  number  of  alterations  in  the  appendages  of  the  eye ;  and  it 
may  indeed  successively  destroy  every  part  of  the  organ  of 
vision. 

At  the  commencement  of  the  first  stage,  the  eyelids  are  slightly 
red  and  tumefied,  and  nothing  more  is  seen  than  a  red  trans 
verse  line  in  the  centre  of  the  eyelid.  The  child  cannot  bear  the 
light,  but  turns  its  head  in  an  opposite  direction  whenever  the 
candle  or  other  shining  object  is  brought  before  it,  and  also  cries 
when  the  pyelids  are  touched.     Pain  or  itching  will  sometimes 

♦  Injlammation  de  la  membrane  muq.  gastro-pulm.  chat  Us  nouveau-ncs.  Paris, 
1823.  p.  16. 


ON   THE    DISEASES    OF    INFANTS.  603 

excite  continual  crying,  and  deprive  it  of  sleep.  The  edges  of 
the  eyelids,  particularly  at  the  internal  angle,  then  begin  to  ap- 
pear red ;  and  if  the  internal  surface  be  examined,  it  will  be 
found  to  be  either  of  a  deep  red,  or  considerably  injected  with 
blood.  The  globe  of  the  eye  exhibits  no  change.  This  is  the 
first  stage  of  infontile  ophthalmia;  it  occurs  on  the  third, fourth, 
or  sixth  day  after  birth,  and  will  continue  a  very  little  time  in 
the  same  condition,  if  left  to  itself 

The  second  stage  is  known  by  the  formation  of  pus  ;  all  the 
preceding  symptoms  are  increased  in  intensity ;  the  injection  of 
the  bloodvessels  is  extended  to  the  globe  of  the  eye  ;  the  redness 
exteriorly  is  greater ;  a  large  quantity  of  pus  is  discharged,  and 
causes  the  edges  of  the  eyelids  to  adhere,  and  the  pus  accumu- 
lates in  the  sac  thus  formed,  and  when  the  lids  are  separated 
pus  immediately  flows  out;  the  child  is  unable  to  open  the  eyes, 
both  on  account  of  swelling  and  the  impossibility  of  bearing  the 
light.  The  conjunctiva,  which  is  also  inflamed  in  this  stage  of 
the  disease,  becomes  of  a  deep  red  ;  the  folds  of  this  membrane, 
which  exist  between  the  globe  and  the  e^^elid,  swell,  and  are  cov- 
ered with  a  number  of  very  small  granulations ;  and  as  these 
folds  compress  and  force  out  the  tarsal  cartilages,  they  thereby 
cause  an  inversion  of  the  eyelids  to  a  greater  or  less  extent 
whenever  the  child  cries  :  two  red  fungous  rings  are  observed 
between  the  eyelids.  While  the  inflammation  increases,  the  sup- 
puration becomes  more  abundant;  it  varies  much  as  to  its  color 
and  consistence:  it  is  usually  thick  and  of  a  light  yellow,  and 
sometimes  mixed  with  blood,  occasionally  in  large  quantities. 
In  an  advanced  stage  of  the  disease  it  assumes  a  green  color ; 
and  I  have  also  seen  it,  in  children  affected  with  jaundice,  of  a 
deep  yellow. 

I  remarked  that  the  inflammation  passed  from  the  eyelids  to 
the  globe  of  the  eye.  When  it  affects  the  latter  it  produces  some 
very  serious  lesions,  which  sometimes  terndiinate  in  the  total  loss 
of  sight,  even  in  the  youngest  infants.  Let  us  take  a  rapid  view 
of  these  complications. 

Inflammation  of  the  cornea,  or  keratitis,  is  the  most  common  ;* 


*  Mirault,  Dissertation  inauguraU  sur  la  keratite,  ou  inflammation  de  la  cornee. 
Paris,  1823. 


504  ON   THE    DISEASES    OF    INFANTS. 

and  several  kinds  of  lesions  are  its  effects,  such  as  its  opacity, 
softening,  ulceration,  and  perforation. 

Opacity,  as  in  adults,  arises  in  consequence  of  an  effusion  of 
puriform  matter  between  the  laminae  of  the  cornea,  or  in  the  sud- 
stance  of  the  conjunctiva,  which  covers  the  globe  of  the  eye.  It 
spreads  to  a  greater  or  less  extent,  and  I  consider  it  as  the  least 
serious  effect  of  puriform  ophthalmia,  as  it  usually  disappears 
upon  the  yielding  of  the  inflammation. 

Softening  is  not  of  unfrequent  occurrence,  and  is  a  much  more 
serious  termination.  When  it  commences,  the  cornea  loses  its 
lustre,  and  exhibits  at  one  or  several  points  a  grayish  or  brown 
tint,  and  the  line  of  demarcation  which  separates  the  healthy 
part  from  the  diseased  portion  may  easily  be  distinguished.  The 
centre  of  this  softening  soon  becomes  perforated,  and  a  commu- 
nication is  established  between  the  external  air  and  the  anterior 
chamber  of  the  eye,  so  that,  as  soon  as  the  perforation  is  complete, 
there  flows  out  a  certain  quantity  of  aqueous  humor.  This 
opening  appears  even  at  the  centre  of  the  globe  of  the  eye  that  is 
opposite  the  pupil.  It  may  be  of  sufficient  size  to  allow  of  the  es- 
cape of  the  crystalline  lens  with  the  aqueous  humor,  and  which 
is  followed  by  some  of  the  vitreous  humor.  The  globe  of  the 
eye  shrinks,  the  eyelids,  on  healing,  close,  and  vision  is  complete- 
ly lost.  I  have,  in  several  instances,  seen  the  iris  project  beyond 
the  borders  of  the  opening,  and  partially  obliterate  it,  and  thus 
prevent  the  flowing  of  any  more  of  the  humors  of  the  eye. 

Ulceration  differs  in  some  respects  from  softening ;  it  usually 
occurs  at  the  opaque  parts  of  the  cornea;  the  edges  are  tumefied, 
and  it  consists  of  small  solutions  of  continuity,  the  sides  of  which 
are  a  little  prominent,  more  round  and  regular  than  in  softening. 
The  same  effects  follow  both  these  varieties  of  the  disease. 

When  the  inflammation  diminishes,  the  swelling  of  the  eyelids 
gradually  ceases.  Suppuration  is  less  abundant,  and  less  green,  and 
thinner.  The  child  is  better  able  to  bear  the  light,  and  can  open 
the  eyelids  with  much  more  facility  ;  but  the  lesions  with  which 
the  membranes  were  affected  continue,  and  children  with  this  de- 
rangement of  parts  may  become  either  partially  or  totally  blind, 
from  the  continuance  of  the  opacity  of  the  cornea,  staphyloma,  or 
the  complete  evacuation  of  the  aqueous  humor  and  crystalline 
lens.     The  pupils  remain  more  or  less  deformed,  according  to  the 


ON   THE    DISEASES    OF    INFANTS.  505 

adhesions  they  have  contracted  with  some  of  the  surrounding 
parts.  As  a  general  rule,  the  prognosis  of  ophthalmia  of  infants 
is  unfavorable  in  proportion  as  the  globe  of  the  eye  is  involved  in 
the  inflammation,  and  as  the  constituent  parts  of  this  organ  are 
altered.  The  continuance  of  this  inflammation  is  very  variable. 
When  it  is  simple,  it  lasts  but  for  a  few  days ;  when  complicated, 
with  organic  alterations  of  the  globe  of  the  eye,  it  may  continue 
for  several  weeks  or  months. 

Opacity  and  softening  of  the  cornea  are  not  always  produced 
by  puriform  ophthalmia  alone.  I  have  seen  several  children, 
who  had  been  reduced  to  complete  marasmus  by  gastro-intestinal 
disorders  of  long  duration,  affected,  without  palpebral  inflamma- 
tioUj  with  softening  of  the  cornea,  which  was  followed  by  a  per- 
foration and  a  discharge  of  the  humors  of  the  eye  and  the  crys- 
talline lens.  This  species  of  spontaneous  softening  reminds  me 
of  the  fact  noticed  by  M.  Magendie  in  a  dog,  which,  being  fed  for 
a  long  time  with  sugar,  died  after  having  been  reduced  to  great 
emaciation.  "  There  appeared,"  says  M.  Magendie,  "  on  one 
eye,  and  afterwards  on  the  other,  a  small  ulcer  on  the  centre  of 
the  transparent  cornea ;  it  rapidly  increased  in  size,  and  at  the 
end  of  a  few  days  it  was  about  a  line  in  diameter,  and  its  depth 
increased  in  the  same  proportion ;  the  cornea  was  soon  perfora- 
ted, and  the  humors  of  the  eye  escaped.  This  singular  phenome- 
non was  accompanied  with  an  abundant  secretion  from  the 
glands  of  the  eyelids."*  Was  defect  in  alimentation  a  cause  of 
the  softening  of  the  cornea  ? 

The  first  object  to  be  considered  in  the  treatment  of  this  dis- 
ease is  the  relieving  of  the  inflammation.  It  has  been  recom- 
mended for  this  purpose  to  apply  leeches  to  the  middle  of  the  up- 
per eyelid.  One,  however,  is  sufficient ;  Mr.  Lawrence  observes 
that  a  larger  number  produces  the  discharge  of  too  large  a  quan- 
tity of  blood,  and  that  the  most  robust  infant  is  reduced,  even  by 
the  use  of  one  single  leech,  to  a  state  of  debility  and  paleness.f 
M.  Baron  usually  applies  one  leech  to  the  external  angle  of  each 
eye,  and  I  have  seen  the  most  happy  effects  result  from  this  me- 
thod even  while  the  eyelids  were  very  much  tumefied.  At  the 
same  time  the  eyes  ought  to  be  washed  with  a  collyrium,  made 

*  Precis  elcmentaire  de  physiologic,  t.  ii.,  p.  209. 

t  Practical  Treatise  on  Diseases  of  the  Eyes. 

64 


506  ON   THE    DISEASES    OF    INFANTS. 

with  a  decoction  of  marshmallows  or  of  rosewater.  It  is  the 
practice  in  the  children's  hospital  at  Vienna,  to  have  compresses 
saturated  with  cold  water  kept  continually  applied  to  the  eyes. 
The  edges  of  the  eyelids  should  also  be  frequently  anointed  with 
some  mild  ointment,  to  prevent  their  adhering,  or  to  promote  their 
separation  when  they  have  become  united. 

Mr.  Lawrence  advises,  immediately  on  the  removal  of  the  inflam- 
matory symptoms,  the  use  of  astringent  coUyria.  A  wash,  con- 
sisting of  two,  three,  or  four  grains  of  alum  in  an  ounce  of  water, 
is  usually  employed  for  this  purpose  at  the  ophthalmic  infirmary. 
This  solution  should  be  carefully  injected  between  the  eyelids, 
three  or  four  times  in  twenty-four  hours,  so  as  to  remove  entirely 
all  the  pus.  In  some  cases,  and  where  the  conjunctiva  has  not 
become  inflamed,  astringents  may  be  employed  from  the  com- 
mencement. All  that  is  done  at  the  infirmary  in  London  is  to 
wash  the  eyes  with  a  solution  of  alum,  and  to  give  a  little  mag- 
nesia— a  course  of  treatment  which  has  been  very  successful.  A 
solution  of  the  nitrate  of  silver  may  also  be  advantageously  used, 
in  the  proportion  of  one  or  two  grains  to  an  ounce  of  water,  and 
increasing  it  to  six  grains  to  the  ounce. 


CHAPTER  XV. 


JAUNDICE    OP    INFANTS. 


Jaundice  is  a  yellow  coloring  of  the  integuments,  or  of  the 
proper  tissue  of  one  or  more  of  the  organs.  This  definition  em- 
braces all  the  varieties  of  form,  aspect,  and  extent  of  jaundice, 
but  this  denomination  is  not  applicable  to  every  case  of  yellow  col- 
oring of  the  skin  :  we  shall  presently  see  that  it  may  be  observed 
in  many  parts  of  the  body ;  that  it  may  be  general  or  local, 
and  exhibit  various  shades  of  color  in  diflferent  subjects. 

I  have  remarked  the  yellow  coloring  which  constitutes  jaun- 
dice, in  four  instances,  in  the  brain  and  spinal  marrow  ;  the  brain, 
which  was  of  moderate  firmness,  presented  a  uniform  and  bright 
yellow  in  two  of  these  subjects,  while  the  color  was  in  isolated 
patches  in  the  other  two.     In  three  of  these  cases  the  substance 


ON    THE    DISEASES    OF    INFANTS.  507 

of  the  medulla  was  of  a  deep  yellow,  and  its  consistence  very- 
soft  ;  and  in  the  two  subjects  where  the  yellow  color  of  the  brain 
was  uniform,  there  existed,  at  the  same  time,  a  general  jaundiced 
affection  of  the  skin.  This  yellow  coloring  is  analogous  to  that 
which  M.  Lobstein  has  observed  in  an  embryo,  and  which  he 
has  named  kirronosis. 

I  have  never  seen  it  in  the  lungs,  but  have  only  found  them  in- 
filtrated with  a  large  quantity  of  yellow  serosity  ;  the  tissue  of 
the  heart,  however,  and  the  pericardium,  are  sometimes  of  a  deep 
saffron  color.  The  thymus  gland  also  is  colored  to  a  greater  or 
less  degree.  The  intestinal  tube,  which  very  often  has,  at  its  in- 
ternal surface,  a  yellow  color,  owing  to  the  contact  of  bile,  in  two 
instances  which  I  have  examined,  exhibited  a  yellow  coloring, 
both  on  the  internal  and  external  surfaces,  and  which  also  ap- 
peared on  the  mesentery  and  on  the  external  layer  of  the  perito- 
neum. I  dissected  and  preserved  a  portion  of  this  intestinal 
tube,  and  observed  no  change  in  the  color.  I  have  already  spo- 
ken of  the  yellow  color  which  exists  in  streaks  on  the  kidneys ; 
even  the  bladder  is  sometimes  of  the  same  color  on  its  internal 
surface.  The  liver  is  very  often  yellow  in  young  infants,  and  I 
have  even  on  some  occasions  found  it  deeply  colored,  in  subjects 
where  there  existed  but  little  of  the  jaundice  exteriorly ;  this, 
however,  is  very  rarely  observed.  The  muscles  are  also  colored 
yellow,  but  the  cellular  tissue,  and  adipose  substance  surrounding 
them,  are  perfectly  white.  At  other  times,  the  whole  adipose 
system  is  yellow,  while  neither  the  integuments,  muscles,  nor 
any  of  the  organs  exhibit  this  color.  I  have,  in  two  instances,  es- 
pecially noticed  this  in  young  infants,  and  when  the  thigh  was 
cut  transversely  the  stump  appeared  yellow  in  circular  line  be- 
neath the  skin,  while  neither  the  skin  nor  the  muscles  presented 
any  thing  of  this  color.  I  have  also  found  the  periosteum  and 
the  osseous  tissue  possessing  this  tint,  with  or  without  a  general 
affection  of  a  similar  nature. 

The  external  integuments  are  the  most  ordinary  seat  of  this 
disease.  Their  color  varies  from  a  light  to  a  greenish  yellow ; 
and  it  is  sometimes  confined  to  the  face,  and  sometimes  to  the 
limbs  and  trunk ;  it  spreads  successively  from  one  of  these  parts 
to  another,  or  makes  its  appearance  in  some  point  after  having 
disappeared  at  another.    In  the  cutaneous  affection,  the  conjunc- 


608  ON    THE    DISEASES    OF    INFANTS. 

tiva  is  also  very  often  yellow ;  but  this  coincidence  is  much  less 
frequent  in  children  than  in  adults.  It  is  very  common  to  find 
the  serosity  of  the  cellular  tissue  of  the  pleura  and  pericardium, 
and  also  of  the  peritoneum,  tinged  with  yellow.  The  color  of 
the  urine  and  foBcal  matter  varies  considerably;  the  pus  se- 
creted from  inflamed  organs  is  often  of  the  same  hue ;  the  serum 
of  the  blood  is  almost  always  yellow. 

In  eighty  cases  of  jaundice,  I  found  in  fifty  the  liver  and  the 
abdominal  vessels  engorged  with  blood,  and  I  have  recorded 
forty  cases  of  hepatic  congestion  without  jaundice.  In  the 
eighty  cases  just  mentioned,  1  found  the  bile  more  yellow  and 
more  abundant  than  ordinary  in  only  two.  I  have  remarked 
that  icterous  affection  of  the  skin  follows  the  red  color,  so  com- 
mon in  infants,  and  always  in  a  gradual  manner.  While  the 
skin  of  the  child  is  still  very  red,  there  is  to  be  seen  a  yellow 
shade,  and  if  the  finger  be  applied  so  as  to  make  a  ]  ittle  pressure, 
instead  of  becoming  white  it  exhibits  a  yellow  tinge,  and  returns 
to  the  red  color  when  the  pressure  is  withdrawn :  the  jaundice 
becomes  slowly  more  evident,  and  about  the  third,  fourth,  or 
eighth  day,  it  takes  the  place  of  the  red,  and  is  in  its  turn  re- 
placed by  the  white,  or  delicate  rose  color  peculiar  to  the  skin 
of  young  infants :  it  would  appear,  then,  that  jaundice  was  a 
shade  or  intermediate  color  between  the  tegumentary  congestion 
of  new-born  children,  and  the  proper  white  color  of  their  in- 
teguments. 

From  this  exposition  of  facts,  it  results,  1st,  That  jaundice, 
being  sometimes  local,  cannot  arise  from  a  general  cause,  which 
would  extend  its  morbid  influence  over  every  part  of  the  body, 
as  diseases  of  the  liver,  for  example,  to  which  it  has  been  usual 
to  attribute  it ;  and  M.  Lobstein  has  remarked,  besides,  that  the 
medulla  spinalis  is  sometimes  colored  yellow,  at  a  period  anterior 
to  the  secretion  of  bile.  2dly,  The  liver  and  the  bile  are  found 
to  be  in  cases  of  jaundice  in  very  variable  conditions,  and  it 
would  be  difficult  to  explain  what  would  be  the  pathological 
state  of  this  organ,  or  of  its  secretion,  to  produce  the  disease  in 
question.  3dly,  Notwithstanding  the  sanguineous  congestion 
of  the  liver  and  integuments  coexisting  with  jaundice  in  the 
greatest  number  of  instances,  it  is  probable  that  the  retention  of 
this  fluid  in  the  organs,  and  the  deposition  of  serum,  which  is 


ON.  THE    DISEASES    OF    INFANTS.  509 

almost  always  yellow,  is  the  cause  of  jaundice  ;  a  color  owing 
either  to  the  coloring  principle  of  the  bile,  as  appears  to  be  proved 
from  the  experiments  of  M.  Chevreul,  or  to  a  source  still  un- 
known. 

In  every  instance,  the  jaundice  of  infants  cannot  be  considered 
as  a  disease  ;  it  may  safely  be  left  to  nature,  and  it  will  of  itself 
disappear ;  the  use  of  medicine  is  unnecessary,  unless  there 
should  arise  some  affection  of  the  cerebral,  thoracic,  or  abdomi- 
nal organs. 

The  English  pathologists,  Armstrong,  Underwood,  together 
with  Dr.  Dewees  and  others,  have  made  a  distinction  between 
jaundice  of  new-born  children,  and  that  which  is  symptomatic 
of  affections  of  the  liver :  they  have  founded  this  distinction  on 
the  appearance  of  the  alvine  evacuations,  which  in  the  latter 
disease  are  white  or  yellowish ;  the  tears  also  and  other  secre- 
tions are  tinged  of  the  same  color.  These  symptoms,  however, 
indicate  nothing  more  than  a  greater  degree  of  ordinary  jaundice, 
but  do  not  establish  a  sufficient  difference  in  the  disease  to  war- 
rant the  employment  of  any  additional  therapeutic  means. 


CHAPTER  XYI. 

ACCIDENTAL    TISSUES    IN    INFANTS. 

Accidental  tissues  are  not  of  very  common  occurrence  in 
young  infants ;  for  they  appear  to  be  produced  by  the  organic 
modifications  occurring  in  the  organs  during  their  growth  in  the 
course  of  life.  I  have  found  but  two  kinds  of  accidental  tissues 
in  the  great  number  of  bodies  that  I  examined  in  the  year  1826. 
These  were  scirrhous  and  tuberculous. 

One  of  these  cases,  that  of  scirrhous,  occurred  in  an  organ 
where  it  is  seldom  or  ever  found  in  an  adult, — that  of  the  heart. 
The  following  is  the  history  of  this  curious  fact 

CASE  LXXXVI. — Scirrhus  of  the  heart. — Courtmi,  aged  three 
days,  was  brought  to  the  Hospice  des  Enfans  Trouves  on  the  4th 
of  November,  1826,  and  died  the  next  day.     The  post  mortem  ex- 


510  ON   THE    DISEASES    OF    INFANTS. 

amination  was  made  twenty-four  hours  after  death  ;  externally,  the 
body  exhibited  a  considerable  embonpoint,  and  the  integuments  were 
violet  colored.  A  general  passive  congestion  was  found  in  the  in- 
testinal tube.  The  lungs  were  healthy ;  the  heart,  which  was  of  the 
usual  size,  exhibited  at  its  anterior  part  three  white  prominences  of 
unequal  volume,  and  flattened  anteriorly  and  very  near  each  other. 
The  largest  was  near  the  base  of  the  heart;  the  one  next  in  size  was 
nearer  the  summit  of  the  organ,  and  the  smallest  between  them. 
They  were  imbedded  in  the  substance  of  the  left  ventricle  and  of  the 
septum,  and  projected  on  the  internal  surface  of  the  heart.  This 
was  very  hard  when  cut,  and  exhibited  fibres  crossing  each  other, 
the  appearance  and  form  of  which  were  analogous  to  the  tissue  of 
scirrhous.  When  placed  in  contact  with  nitric  acid,  this  substance 
became  crisp  and  black ;  the  same  phenomena  occurred  when  placed 
on  hve  coals,  it  did  not  melt  like  fat.  The  surrounding  tissue  of  the 
heart  was  perfectly  healthy;  and  every  thing  led  to  the  belief  that 
these  tumors  were  not  formed  by  the  adipose  tissue.  I  do  not  know 
to  what  cause  to  attribute  the  formation  of  this  tissue  in  an  infant 
who  must  have  necessarily  been  born  with  this  disorganization.  I 
was  unable  to  obtain  any  account  of  the  mother's  health. 

Tubercles. — There  have  been  several  instances  reported  of  the 
existence  of  tubercles  in  various  parts  of  the  body  of  a  foetus. 
1  have  found  tubercular  granulations  in  the  peritoneum  of  a 
child  that  died  four  days  after  birth ;  in  two  still-born  children 
I  saw  an  evident  tubercular  disease  of  some  of  the  mesenteric 
glands.  OElher  has  found  the  mesenteric  glands  tumefied,  hard- 
ened, and  in  a  word  scrofulous,  not  only  in  children  born  of 
scrofulous  mothers,  but  also  in  those  whose  mothers  exhibited 
no  sign  of  this  disease.*  Tubercular  granulations  of  the  spleen 
are  not  very  rare  in  young  infants ;  I  have  seen  them  in  five 
children,  where  there  existed  at  the  same  time  in  two  of  them 
tubercles  in  the  lungs.  We  should  be  careful  not  to  mistake 
tumors  arising  from  duplicate  monstrosity,  in  which  may  be  dis- 
covered the  fragments  of  a  foetus,  for  an  accidental  organic 
transformation. 

Tubercles  in  the  lungs  have  been  seen  both  in  stillborn  chil- 
dren and  those  born  before  the  full  time.     M.  Husson  reported 

♦  Art.  OEuf.  (path.)  Diet,  de  Medic,  t.  xv.,  p.  402. 


ON   THE    DISEASES    OP    INFANTS.  511 

to  the  Academie  royale  de  medecine  the  cases  of  two  children 
that  he  dissected,  the  one  born  at  the  seventh  month,  the  other 
at  the  full  time,  and  that  lived  eight  days,  where  the  tubercles 
were  found  softened,  and  already  in  a  state  of  suppuration,  in 
the  former  case  in  the  lungs,  although  the  mother  had  not  been 
affected  with  phthisis,  and  the  latter  in  the  liver.* 

During  the  year  1826,  I  met  with  four  cases  of  pulmonary 
tubercles  in  infants  that  died  at  the  age  of  one,  two,  and  five 
months.  They  all  at  the  time  of  birth  exhibited  an  activity  and 
embonpoint  which  would  not  allow  of  the  supposition  that  there 
existed  the  organic  alterations  with  which  they  were  affected. 
They  gradually  fell  into  a  state  of  debility  and  marasmus  ;  the 
abdomen  became  tympanitic,  their  cry  was  changed,  and  in  two 
of  them  percussion  was  not  followed  by  the  sound  which  is  na- 
tural to  this  age  ;  this  circumstance  induced  the  belief  that  there 
existed  tubercles,  which  were  found  in  great  numbers  on  a  post 
mortem  examination.  Neither  of  these  children  were  affected 
with  the  symptoms  peculiar  to  phthisis  of  adults,  such  as  bron- 
chial catarrh,  hoemoptysis,  sweating,  and  coliquative  diarrhoea; 
one  only  had  diarrhoea  ;  the  mesenteric  glands  in  this  case  were 
found  in  a  tuberculous  condition,  with  follicular  ulceration  in 
the  intestines  ;  the  child  thus  affected  was  the  one  aged  five 
months.  One  of  the  others  had,  for  three  days,  symptoms  which 
appeared  to  indicate  the  existence  of  a  severe  laryngitis :  it  died 
from  suffocation.  On  examining  the  dead  body,  the  trachea, 
bronchise,  and  lungs  were  found  in  the  following  condition : 
the  pleura  was  covered  with  a  large  number  of  small,  slightly 
prominent,  white  granulations ;  the  larynx  and  trachea  were 
healthy ;  the  bronchise  contained,  at  their  commencement,  some 
frothy  mucosity  ;  the  left  bronchia  was  filled  with  a  thick  puri- 
form  fluid.  There  existed  at  the  root  of  the  left  lung  an  irregu- 
lar tubercular  mass  still  in  a  crude  state,  compressing  the  oppo- 
site branch  in  such  a  manner  as  scarcely  to  permit  the  air  to 
pass.  The  internal  membrane  of  this  bronchia  was  red  and 
tumefied  at  the  place  of  its  stricture.  The  pulmonary  tissue 
was  white  and  flabby,  and  the  bronchial  ramifications  shrunk. 
The  other  lung  was  quite  permeable  to  the  air,  and  was  per- 

*  Art.  OEuf.  (path.)  Diet,  de  Medic,  t.  xv.,  p.  402, 


512  ON   THE    DISEASES    OF    INFANTS. 

fectly  healthy,  with  the  exception  of  some  very  small,  transpa- 
rent, tubercular  granulations  scattered  throughout  its  tissue. 

"Pulmonary  tubercles,  for  the  most  part,  in  those  children  that 
I  have  dissected,  appear  under  the  form  of  small,  round,  trans- 
parent granulations,  disseminated  on  the  surface  and  tissue  of 
the  lungs,  either  at  the  extreme  branches  of  the  bronchias,  or  in 
the  spaces  between  them ;  whilst  tubercles  in  a  more  advanced 
stage,  and  even  in  a  state  of  suppuration,  appear  at  the  root  of 
the  bronchiiB,  or  in  the  trachea.  It  would  seem  from  this  that 
the  tubercular  transformation  of  the  lymphatic  ganglia,  situated 
at  the  root  of  the  lungs  and  in  the  vicinity  of  the  bronchial  ram- 
ifications, takes  place  first,  and  that  a  similar  transformation 
afterwards  occurs  in  the  lungs  ;  can  we  not  also  suppose  that,  in 
the  beginning,  the  pulmonary  tubercles  consist  of  small  granu- 
lations, appearing  at  first  transparent  and  soft,  but  when  in- 
creased in  number  unite,  and  thus  form  the  tubercular  masses 
which  we  meet  with  in  the  lungs  at  a  more  advanced  age? 
This  form  of  pulmonary  tubercles,  more  common  than  any  other 
at  the  early  period  of  life,  appears  to  reveal  the  primitive  mode 
of  development  of  pulmonary  tubercles. 


CHAPTER  XVII. 

ALTERATION    OF    THE    BLOOD. 


In  the  bodies  of  three  stillborn  children,  that  were  in  a  state 
of  general  decomposition,  and  to  which  I  was  at  a  loss  to  assign 
a  cause,  I  discovered  what  appeared  to  me  to  be  a  well-marked 
alteration  in  the  blood.*     The  small  number  of  well-ascertained 

*  In  these  three  cases,  it  was  impossible  to  ascertain  the  state  of  the  mothers  at  the  time 
of  labor.  I'here  is  no  doubt  that  the  health  of  the  mothers  had  a  direct  influence  on 
that  of  their  children ;  numerous  examples  have  long  since  demonstrated  this  fact,  and 
in  the  present  instances,  there  is  in  all  probability  an  analogous  coincidence.  There 
is  a  case  recorded  in  the  Archives  gen  de  med.,  tom.  xv.,  p.  92,  of  decomposition  of  the 
blood,  accompanied  with  general  petechise,  in  a  woman  that  died  just  before  the  full 
time  of  her  pregnancy.  The  condition  of  the  foetus  was  as  follows :  it  was,  as  usual, 
covered  with  a  quantity  of  casseous  matter ;  the  ejadermis  was  raised  at  the  feet,  hands, 


ON  THE    DISEASES    OP    INFANTS*  513 

facts  published  on  the  alterations  of  the  fluids  in  diseases,  will 
not  permit  at  present  of  the  establishment  of  any  fixed  and  posi- 
tive theory ;  I  will  therefore  merely  point  out  the  facts  which  I 
have  observed,  as  a  contribution  to  the  history  of  the  diseases  of 
the  fluids. 

In  eight  children,  who  had  not  lived  beyond  the  eleventh  day, 
and  who  had  sunk  under  pneumonia  and  gastro-enteritis,  I  found 
a  general  discoloration  of  the  body,  accompanied  with  complete 
marasmus,  without  decomposition  of  the  integuments  or  destruc- 
tion of  the  epidermis.  When  incisions  were  made  in  different 
parts  of  the  body,  there  flowed  out  a  large  quantity  of  very  fluid 
chocolate-colored  blood ;  the  mucous  membrane  of  the  digestive 
tube  exhibited  in  almost  all  the  cases  the  discoloration  and  white 
softening  which  I  have  described  in  the  chapter  on  diseases  of 
the  digestive  tube.  The  liver  was  gorged  with  fluid  blood,  and 
similar  in  color  to  that  of  the  integuments ;  the  lungs  were  in 
the  same  condition,  and  quite  soft ;  the  heart  also  was  pale  and 
flabby,  and  in  the  same  state  of  congestion.  The  foetal  openings 
were  obliterated  in  almost  all ;  in  some  the  brain  was  firm  and 
without  injection ;  in  the  greatest  number  it  was  softened,  and 
in  two  I  found  it  decomposed,  and  diff'using  an  odor  of  sulphu- 
retted hydrogen.  In  four  others,  I  found  the  liver  also  softened, 
exhibiting  the  same  odor.  The  bile  did  not  present  any  thing 
peculiar.  The  whole  of  the  tissues  were  remarkable  for  their 
softness,  flaccidity,  and  their  near  approach  to  a  true  decomposi- 
tion. In  several  others,  the  limbs  were  oedematous,  and  the 
skin  had  the  appearance  of  wax.  They  had  all  been  affected 
with  an  extreme  slowness  of  the  circulation,  and  great  prostra- 
tion ;  their  cries  were  feeble,  and  they  continued  for  two  or  three 
days  in  a  kind  of  agony,  which  death  soon  terminated,  without 
giving  rise  to  any  particular  symptom. 

and  scrotum.  There  was  no  ecchymosis  on  any  part  of  the  body.  The  brain  was 
injected  with  fluid  blood ;  the  lungs,  pericardium,  heart,  and  origin  of  the  great  vessels, 
were  covered  with  purple  spots  of  a  small  size.  The  liver,  spleen,  intestinal  canal, 
kidneys,  and  bladder  were  in  a  healthy  state. 

All  the  blood  that  flowed  from  the  cut  parts,  together  with  that  which  was  contained 
in  the  different  vessels,  both  of  the  mother  and  foetus,  was  fluid  and  violet,  resembling 
a  mixture  of  carmine  and  water.  In  no  part  of  the  body  was  there  found  the  smallest 
clot. 


514  ON   THE    DISEASES    OF    INFANTS. 

Death  in  these  children  appeared  to  be  caused  more  by  a  kind 
of  spontaneous  decomposition  of  the  solids  and  fluids,  than  by 
the  progress  of  any  inflammatory  disease,  or  of  any  organic 
lesion.  Does  not  this  species  of  death  bear  some  resemblance  to 
the  withering  and  disorganization  of  vegetables,  rather  than  to 
those  alterations  which  occur  in  the  organs  of  a  being  in  pos- 
session of  all  the  plenitude  of  life  ?  And  the  patient,  when  sink- 
ing under  them,  manifests  symptoms  of  reaction  which  may,  in  a 
metaphoric  sense,  be  considered  as  the  effect  of  a  kind  of  strug- 
gle between  death  and  life.* 

♦  Although  the  important  remarks  of  Dr.  Joerg,  in  his  work  on  diseases  of  children, 
p.  310,  may  perhaps  have  but  an  indirect  reference  to  the  preceding  facts,  yet  from  their 
interesting  character  we  shall  place  them  here.  A  very  important  disease  of  the  skin 
in  young  infants,  says  he,  is  that  which  is  characterized  by  a  peculiar  state  of  the  epi- 
dermis, which  is  detached  on  the  sHghtest  touch  from  the  sole  of  the  foot,  toes,  palm 
of  the  hands,  fingers,  and  even  sometimes  from  the  entire  surface  of  the  body.  I  have 
only  once  seen  this  general  separation  of  the  skin  in  a  child  in  perfect  health,  and  born 
at  the  full  time ;  but  have  frequently  met  with  it  on  the  hands  and  feet.  In  every  case 
the  mother  had  been  affected  with  syphilis  during  pregnancy.  None  of  the  children 
thus  affected  lived  longer  than  four  or  five  days,  and  although  born  in  the  ninth 
month,  they  were  all  thin  and  debilitated.  The  part  deprived  of  the  epidermis  became 
inflamed,  and  this  circumstance,  joined  to  the  extreme  debility  of  the  individuals,  con- 
tributed greatly  to  shorten  their  lives.  I  am  entirely  ignorant  of  the  nature  of  this 
disease.  This  state  of  the  skin  on  the  hands  and  feet  is  sometimes  accompanied  with 
a  pustular  eruption  on  various  parts  of  the  body,  differing  essentially  from  the  small- 
pox in  the  form  and  appearance  of  the  pustules.  They  bear  some  resemblance,  how- 
ever, to  the  pustules  of  vaccinia  on  the  twelfth  or  thirteenth  day.  It  has  been  likewise 
impossible  for  me  to  ascertain  any  thing  satisfactory  as  to  the  nature  and  progress  of 
this  eruption,  from  the  extreme  rapidity  with  which  all  children  die  that  are  affected 
with  this  singular  disease.     {Archives  gen  dc  med.,  torn,  xxiii.,  p.  560. 


A 

MEDICO-LEGAL  DISSERTATION 

ON 

VIABILITY, 

CONSIDERED  WITH  REFERENCE  TO  THE  PATHOLOGY  OF  NEW- 
BORN CHILDREN. 


Viability  is  the  capability  of  extra-uterine  life;  it  should 
consist  not  only  in  the  normal  state  of  the  organs  of  the  infant, 
but  likewise  in  the  absence  of  all  physiological  and  pathological 
causes,  capable  of  opposing  the  establishment  or  prolongation  of 
independent  existence.  Thus,  as  Professor  Orfila  has  observed,  an 
infant  may  have  lived,  and  yet  not  have  been  regarded  as  viable, 
because  some  organic  malformation  may  have  prevented  the 
prolongation  of  life  ;  another  child,  born  living,  may  perish  in 
the  first  period  of  its  life,  although  it  was  viable.* 

The  question  of  viability,  then,  must  be  considered  with  ref- 
erence to  the  pathological  causes  which  may  be  adverse  to  the 
establishment  of  life,  and  it  is  therefore  necessary  to  have  a  pro- 
per estimate  of  these  causes.  It  appears  to  me  useful  to  ascertain 
how  far  congenital  malformations  and  diseases  of  the  new-born 
child  may  embarrass  the  establishment  of  life,  for  all  congenital 
diseases  are  not  productive  of  non-viability ;  some  offer  no  im 
pediment  to  the  establishment  and  continuance  of  independent 
life,  while  others  clog  and  embarrass  its  development ;  the  latter 
are  the  inevitable  causes  of  the  death  of  the  child,  and  the  study 
of  their  nature  is  the  object  of  this  dissertation. 

The  various  apparatuses  and  principal  organs  of  the  system 
will  be  reviewed,  and  the  congenital  malformations  and  diseases 
which  may  be  developed  during  the  evolution  of  the  foetus  ex- 

*  Legons  de  Medecine  Legale^  2d  edit.,  p.  511. 


516  DISSERTATION    ON    VIABILITY. 

amined.  I  shall  divide  this  subject  into  two  parts ;  the  first  will 
comprise  the  study  of  congenital  diseeiseSj  and  that  of  their  influ- 
ence upon  the  development  of  life ;  and  the  second  the  applica- 
tion of  these  data  to  legal  medicine.* 


PART  FIRST. 

ON  CONGENITAL  MALFORMATIONS  AND  DISEASES. 

§  I.  Congenital  malformations  of  the  skin. — Care 
must  be  taken  not  to  mistake  for  a  congenital  disease  the  intense 
redness  of  the  skin  of  a  new-born  child,  and  the  epidermic  exfo- 
liation which  occurs  several  days  after  birth  ;  both  of  these  are 
natural  phenomena. 

Absence  of  the  skin  in  one  or  more  parts  of  the  body  has  been 
noticed  from  the  highest  antiquity,  an  account  of  this  lesion  being 
found  in  the  writings  of  Hippocrates,  who  has  made  it  the  sub- 
ject of  some  very  judicious  observations.!  This  congenital  mal- 
formation is  not  adverse  to  the  establishment  of  life  in  an  infant, 
except  when  there  coexists  some  other  deformity,  or  when  an 
organ  is  exposed  which  is  essential  to  life.  Thus,  absence  of  the 
skin,  with  a  wound  on  the  limbs  or  face,  is  susceptible  of  cicatri- 
zation after  birth,  and  can  oppose  no  obstacle  to  the  execution  of 
the  functions  of  life  ;  but  when  absence  of  the  skin  results  from 
an  arrest  of  the  development  of  the  thoracic,  abdominal,  or  cranial 
parietes,  this  malformation  must  be  fatal,  for  important  organs  are 
thereby  deprived  of  their  integuments,  and  the  child  is  exposed  to 
the  most  serious  and  fatal  affections. 

Cutaneous  excrescences,  which  are  met  with  on  the  face,  hands, 
and  feet,  are  not  causes  of  non-viability,  at  least  if  unaccompa- 
nied with  a  defective  development  in  some  other  part ;  which, 
however,  as  Meckel  observes,  is  of  common  occurrence.     Thus, 

*  The  facts  which  furnish  the  matter  for  this  dissertation  being  contained  in  the  nu- 
merous cases  throughout  this  work,  it  is  impossible  to  avoid  some  repetitions  ;  but  on 
reflection,  it  will  be  seen  that  it  was  indispensable  to  recal  all  the  examples  which  con- 
cur in  the  demonstration  of  the  various  points  we  have  undertaken  to  elucidate, 
t  De  Geniturd^  cap.  6. 


DISSERTATION    ON    VIABILITY.  517 

the  cutaneous  excrescence  which  is  seen  on  the  forehead  of  a 
foetal  Cyclops  is  not  a  dangerous  deformity,  except  when  it  co- 
exists with  some  other  congenital  malformation.  Those  cutane- 
ous excrescences  which  are  met  with  on  the  face  alone,  may  be 
removed  and  cured  without  injury  to  the  health  of  the  child. 

It  is  the  same  with  horny  excrescences  ;  but  their  existence  on 
the  human  foetus  is  scarcely  yet  proved,  and  the  passage  which 
Haller  has  devoted  to  these  extraordinary  growths  has  no  foun- 
dation but  in  facts  very  slightly  authenticated. 

The  excessive  development  of  the  pilous  system  at  birth,  must 
be  considered  as  an  abnormal  persistence  of  the  hairs  which  cover 
the  foetus  about  the  middle  of  the  intra-uterine  life,  and  which 
generally  fall  off  before  birth.  Far  from  considering  these  infants 
as  animals  deprived  of  their  faculties,  and  consequently  of  the 
rights  of  civilization,  as  some  ignorant  persons  have  done,  ac- 
cording to  the  account  of  Haller,*  they  ought  to  be  exarriined 
with  care,  to  see  if  there  exist  no  other  organic  aberration  or  some 
disease  of  the  internal  organs,  which  are  adverse  to  the  establish- 
ment of  life,  for  this  simple  abnormal  development  of  the  pilous 
system  cannot  be  a  cause  of  non-viability.  These  hairs  fall  off 
some  time  after  birth,  and  the  infant  then  no  longer  exhibits  this 
superficial  and  transitory  anomaly,  which  ignorance  alone  could 
confound  with  the  integuments  of  animals. 

Alterations  in  the  color  of  the  skin  may  be  referred  to  petechiae, 
albinism,  and  cyanosis.  Albinism  can  have  no  influence  on  yia- 
biUty ;  petechiae  and  cyanosis,  which  are  frequently  seen  in  in- 
fants at  birth,  are  ordinarily  the  symptoms  of  affections  more  or 
less  serious,  which  doubtless  may  oppose  the  establishment  of 
life  :  but  attention  must  be  paid  more  to  these  lesions  than  to  the 
modification  of  the  cutaneous  pigment,  which  is  of  but  little  im- 
portance when  separately  considered.  As  to  albinism,  it  exerts 
no  influence  in  opposition  to  the  prolongation  of  life,  and  albinos 
have  been  seen  at  an  advanced  age.t 

Ecchymoses,  sanguineous  tumors,  contusions  of  the  integu- 
ments, which  ordinarily  result  from  a  local  or  general  sanguine- 
ous congestion,  ought  always  to  be  considered  with  reference  to 

*  Opera  minora. — Dc  monstris,  lib.  i. 

t  J.  Geoffroy-Saint-Hilaire,  Histoire  generale  et  particuliere  des  anomalies  de  I'organi- 
eation  dans  Thomme  et  les  animaux.     Paris,  1832. 


518  DISSERTATION    ON    VIABILITY. 

the  causes  which  produce  them ;  of  themselves  they  are  of  no 
consequence.  The  spots  and  erectile  tumors,  which  are  described 
under  the  name  of  nmvi  materni^  have  no  power  over  the  via- 
bility of  children,  because  they  may  live  a  long  time  with  this 
deformity,  which  does  not  become  mortal  unless  it  is  of  great 
extent,  or  makes  rapid  progress. 

Congenital  inflammations  of  the  skin  deserve  the  attention 
of  the  medical  jurist.  Infants  have  been  born  with  measles  or 
smallpox.  Examples  are  given  by  Bartholin,  Boerhaave,  Van 
8wieten,  Vogel,  Jenner,  Mauriceau,  MM.  Rayer,  Duges,  and 
others.  Some  of  them  were  feeble  and  premature,  and  died  a 
short  time  after  birth.  Children  have  been  cured  of  these  affec- 
tions and  lived  a  long  time  after.  Consequently,  if  these  inflam- 
mations of  the  skin  are  unaccompanied  with  any  congenital  mal- 
formation, or  any  other  serious  disease,  they  ought  not  to  be  con- 
sidered as  an  obstacle  to  the  establishment  of  independent  life. 

Induration  or  oedema  of  the  cellular  tissue  never  exists  alone, 
but  is  almost  always  accompanied  with  a  state  of  congestion  of 
the  principal  organs,  and  particularly  of  the  respiratory  and  cir- 
culatory apparatus.  This  congestion  is  evidently  adverse  to  the 
establishment  of  life,  and  offers,  as  we  shall  see  below,  a  great 
hindrance  to  the  viability  of  the  child.  It  is  not,  therefore,  to 
the  oedema  alone  that  we  ought  to  direct  our  attention,  when 
about  to  pronounce  a  judgment  on  the  viability  of  an  infant  thus 
affected,  but  we  ought  to  ascend  to  the  examination  of  the  accom- 
panying lesions.  As  to  those  infants  described  by  Uzembezius, 
that  were  born  so  cold  and  hard  that  they  might  have  been  mis- 
taken for  marble  statues,  no  doubt  can  exist  as  to  their  non-via- 
bility, since  they  are  almost  always  born  dead.  This  kind  of  in- 
duration of  the  cellular  and  adipose  tissue  is  generally  the  effect 
of  decomposition. 

§  II.  Digestive  apparatus. — Absence  of  the  buccal  cavity, 
and  also  the  absence  of  the  anterior  opening  of  the  mouth,  re- 
placed sometimes  only  by  an  irregular  orifice,  situated  at  some 
part  of  the  buccal  cavity,  ought  to  be  considered  as  a  cause  of 
non-viability  ;  as  it  is  impossible  for  the  child  to  exercise  suction 
or  deglutition,  and  it  is  even  impossible  to  introduce  drinks  into 
the  digestive  passages.  It  is  not  so,  however,  with  the  more  or 
less  perfect  occlusion  of  the  mouth,  in  consequence  of  adhesions 


DISSERTATION    ON    VIABILITY.  619 

of  the  lips ;  this  deformity  does  not  necessarily  affect  the  viabili* 
ty ;  for,  by  means  of  an  operation,  a  passage  may  be  established 
to  the  diofestive  orgfans.  But  when  the  absence  of  the  mouth  co- 
exists  with  a  congenital  malformation  of  the  face  and  cranium, 
this  deformity  ought  to  be  regarded  as  a  cause  of  non-viability. 

The  same  may  be  observed  with  regard  to  congenital  division 
of  the  lips,  palatine  arch,  and  velum.  The  child  may  hve  a  long 
time,  whether  no  effort  be  made  to  relieve  the  infirmity,  or  an 
operation,  which  is  most  frequently  successful,  be  performed  for 
that  purpose.  A  monstrous  development  of  the  tongue  is  not  an 
insurmountable  obstacle  to  the  functions  of  life.  In  the  15th 
volume  of  the  Journal  de  Medecine  de  Vandermonde,  is  record- 
ed an  account  of  a  child  born  with  a  tongue  of  enormous  size, 
the  inferior  extremity  of  which  adhered  to  the  gums  of  the  lower 
jaw,  by  a  spongy  tumor  about  the  size  of  a  filbert.  After  a 
while,  this  tumor  became  confounded  with  the  tissue  of  the 
tongue,  which  steadily  increased  in  size  as  the  infant  advanced 
in  age.  During  this  time,  the  child  was  sustained  only  by  liquid 
aliments ;  it  had  become  habituated  to  the  practice  of  sucking 
by  drawing  the  lower  jaw  considerably  backward ;  at  last,  in- 
structed by  its  wants,  it  was  enabled  to  arrange  the  tongue  and 
jaw  so  as  to  chew  and  articulate  sounds.  This  child,  therefore, 
in  spite  of  this  infirmity,  was  viable,  and  was  much  more  so  be- 
cause the  tongue  might  have  been  reduced  in  size  by  an  opera- 
tion, and  the  proper  form  and  use  of  the  organ  restored.  Children 
are  sometimes  born  with  passive  congestions  of  the  mouth  and 
tongue,  which  can  have  no  influence  on  the  development  of  life. 

The  extreme  narrowness  of  the  pharynx  I  have  observed  to 
coexist  with  that  of  the  tongue  ;  it  interferes  much  with  degluti- 
tion, but  cannot  be  considered  as  a  cause  of  non-viability. 

Congenital  malformations  of  the  oesophagus  are  almost  always 
mortal :  one  species,  that  of  stricture  of  the  oBsophagus,  may  al- 
low the  infant  to  swallow  drinks,  although  with  difficulty  ;  but 
it  is  not  so  with  obliteration,  fissure,  or  duplicity  of  the  oesophageal 
canal.  Infants  affected  with  obliteration  of  the  oesophagus  may 
exhibit  congenital  malformations  externally,  and  which  alone 
would  remove  all  doubts  that  might  be  raised  upon  the  medico- 
legal question  of  which  we  are  treating  ;  such  is  the  case  in  the 
instance  given  by  M.  Lallemand,  of  Montpelier,  in  his  inaugural 


520  DISSERTATION   ON    VIABILITY. 

dissertation.  Dr.  Sunderland,  of  Barmen,  has  given  the  history 
of  a  child  born  at  the  full  time,  and  to  appearance  in  good  condi- 
tion, that  died  at  the  end  of  eight  days,  after  having  continually- 
vomited  the  aliments  which  had  been  given.  On  opening  the 
body,  the  cardia  was  found  wanting ;  the  stomach  adhered  at 
this  place  to  the  diaphragm  by  means  of  the  cellular  tissue.* 
With  such  a  malformation  an  infant  must  necessarily  perish. 
The  same  fatal  result  will  always  occur  when  the  cBsophageal 
canal  is  obstructed,  interrupted,  has  a  deviation  from  its  natural 
direction,  or  is  divided  into  several  parts. 

Congenital  inflammation  of  the  oesophagus,  without  complete- 
ly opposing  the  viability  of  the  child,  may  very  much  disturb  the 
exercise  of  life,  and  at  last  terminate  fatally.  I  have  seen,  in  two 
infants  that  died  a  short  time  after  birth,  ulcerations  which  were 
doubtless  developed  in  the  oesophagus  during  the  latter  part  of 
the  intra-uterine  life,  and  which,  by  the  progress  they  made  after 
birth,  contributed  greatly  to  hasten  the  death  of  these  infants.  It 
is  possible  to  meet  with  a  gelatinous  softening  of  the  oesophagus 
in  a  new-born  child  ;  in  such  an  affection  the  infant  vomits  all 
that  is  given  to  it,  and  becomes  rapidly  emaciated  from  default  in 
nutrition  ;  and  as  the  progress  of  the  disorganization  is  contin- 
ually increasing,  perforations  of  the  oesophagus  are  found  upon 
examining  the  body  after  death.  The  gelatinous  softening  being 
a  disorganization  of  tissue,  and  this  disorganization  having  com- 
menced or  terminated  before  birth,  cannot  be  cured  and  cicatri- 
zed. I  am  therefore  of  opinion  that  it  ought  to  be  regarded  as 
an  inevitable  cause  of  death ;  consequently  infants  that  are  born 
thus  affected  are  not  viable ;  the  chances  of  life  for  them  are  very 
uncertain. 

The  stomach  exhibits  no  anomalies  except  with  reference  to 
its  situation  and  form.  Displacement  of  the  stomach  offers  no 
obstacle  to  life ;  it  can  discharge  its  functions  when  it  is  situated 
upon  the  right  side  as  well  as  the  left  of  the  abdomen,  or  even 
when  it  is  in  the  cavity  of  the  thorax.  The  essential  condition 
is,  that  the  orifices  be  free ;  yet  if  it  be  adherent  to  those  parts 
with  which  in  a  natural  state  it  has  no  communication ;  if,  for 
example,  it  should  open  into  the  colon,  or  occupy  the  place  of  the 

♦  Journal  Complementaire  du  Dictionaire  des  sciences  medicales,  tome  viii.,  p.  369. 


DISSERTATION    ON    VIABILITY.  521 

rectum,  of  which  deviation  instances  have  been  reported,  al- 
though they  are  very  incredible,  it  will  be  easily  conceived  that 
this  infirmity  would  be  regarded  as  one  cause  of  non-viability. 

The  diseases  of  the  stomach  consist  of  different  degrees  of  san- 
guineous congestion  or  of  inflammation.  Congestions  of  the  stom- 
ach arc  of  very  common  occurrence  in  young  infants,  and  con- 
sequently but  little  importance  ought  to  be  attached  to  them  with 
reference  to  the  subject  before  us.  As  to  congenital  inflamma- 
tions, they  are  generally  the  causes  of  very  serious  symptoms. 
Congenital  gastritis  consists  almost  always  of  a  number  of  ulcer- 
ations, the  borders  of  which  are  of  a  very  shining  carmine  hue, 
and  the  bottom  of  a  deep  yellow.  These  ulcers  result  from  the 
disorganization  of  the  muciparous  follicles  of  the  stomach.  The 
portion  of  the  mucous  membrane  surrounding  them  remains 
white,  notwithstanding  the  existence  of  inflammation,  and  the 
stomach  generally  contains  a  quantity  of  black  sanguinolent  mat- 
ters, resulting  from  the  sanguineous  exhalation  which  takes  place 
from  these  ulcers  on  the  surface  of  the  ventricle.  When  thus  af- 
fected, the  child  exhibits  no  external  sign  of  phlegmasia,  and 
preserves  its  rotundity  of  form;  but  as  soon  as  it  is  separated  from 
the  mother,  and  the  gastric  digestion  becomes  a  process  of  the 
greatest  importance,  it  then  falls  into  a  state  of  marasmus,  and 
vomits  all  that  is  given  to  drink ;  brown  matters,  such  as  I  have 
observed  to  exist  in  the  surface  of  the  organ,  are  discharged  by 
vomiting  ;  and  it  soon  perishes  if  the  ulcers,  in  place  of  cicatri- 
zing, enlarge  and  become  more  numerous.  This  alteration  of  the 
stomach  ought  to  be  arranged  among  the  causes  which  interfere 
with  the  development  of  life. 

Gelatinous  softening  of  the  stomach  occurs  sometimes  very 
soon  after  birth,  so  that  one  is  led  to  believe  that  it  has  already 
existed  during  intra-uterine  life.  If  such  an  alteration  should  be 
found  in  an  infant  which  had  died  on  the  first  or  second  day  af- 
ter birth,  ought  it  to  be  pronounced  viable  ?  I  think  not ;  for 
according  to  all  probability  this  alteration  existed  at  the  time  of 
birth  ;  and  it  is  generally  so  rapid  in  its  progress,  and  so  fatal  in 
its  results,  that  a  child  born  with  this  aflfection  should  be  consid- 
ered necessarily  dying,  and  consequently  as  not  born  viable. 

Congenital  malformations  of  the  intestinal  tube  are  very  numer- 
ous.    A  great  number   of  instances  are  recorded  in  various 

66 


522  DISSERTATION    ON    VIABILITY. 

works,  particularly  in  the  learned  one  of  M.  Meckel.*  Doctor 
Schaefer  has  published  a  memoir,  in  which  also  the  principal 
anomalies  of  the  digestive  tube  are  pointed  out.f  Those  which 
more  particularly  deserve  our  attention  are  interruptions  of  con- 
tinuity, strictures,  and  obhterations.  Every  interruption  of  the 
intestinal  canal  ought  to  be  considered  as  a  cause  of  death.  Ob- 
literation will  be  more  dangerous  according  to  its  position.  Thus 
an  infant  having  an  obliteration  at  the  duodenum,  or  some  other 
part  of  the  small  intestines,  at  the  caecum,  colon,  and  the  upper 
two  thirds  of  the  rectum,  ought  to  be  regarded  as  non-viable;  but 
when  the  rectum  exists,  and  the  obliteration  is  near  the  orifice  of 
the  anus,  the  child  might  still  be  considered  as  viable,  since  an 
opening  into  the  anus  has  been  several  times  made  by  an  inci- 
sion through  the  cul-de-sac,  formed  by  the  obliteration  of  the  rec- 
tum. When  this  intestine  is  wanting,  although  it  is  possible  to 
form  an  artificial  anus  at  the  sigmoid  flexure  of  the  colon,  yet 
I  regard  this  condition  as  a  cause  of  non-viability,  inasmuch  as 
the  operation  resorted  to  in  similar  cases  has,  to  this  day,  almost 
always  caused  the  death  of  children,  while  it  is  not  so  when  a 
superficial  incision  is  made  at  the  perinaeum.  Strictures  more 
or  less  numerous  throughout  the  extent  of  the  digestive  canal, 
are  only  embarrassments  to  the  estabhshment  of  life,  but  ought 
not  to  be  considered  as  an  inevitable  cause  of  death. 

Congestions  and  intestinal  hemorrhages,  which  are  observed 
in  infants  at  birth,  phlegmasic  alterations,  such  as  inflammation 
and  ulceration  of  the  muciparous  follicles,  are  also  serious  symp- 
toms, but  not  absolutely  mortal  in  yoimg  infants.  It  is  not 
uncommon  to  see  infants  pass  by  stool,  with  or  without  the  evac- 
uation of  the  meconium,  a  greater  or  less  quantity  of  blood,  the 
result  of  intestinal  exhalation  arising  from  congestion  of  the  intes- 
tines. Infants  do  not  always  die  from  this  cause,  especially  in 
our  climate  ;  but  this  species  of  dysentery  cuts  ofl*,  on  the  contra- 
ry, avast  number  in  America,  where  cholera  infantum  prevails 
epidemically.  If  it  be  proved  that  a  child  can  survive  this  disease, 
it  must  be  admitted  that  it  is  not  essentially  mortal.     This,  how- 

*  Manual  of  Descriptive  and  Pathological  Anatomy.  Translated  by  Dr.  Doane. 
London,  1838. 

t  Journal  complemtfUairt  du  Did.  dcs  sciences  medicales,  t.  24. 


DISSERTATION    ON    VIABILITY.  523 

ever,  is  not  so  with  the  white  or  pultaceous  softening  of  the  mu- 
cous membrane  of  the  intestines.  I  have,  in  three  instances, 
seen  this  disorganization  of  the  mucous  membrane  in  children 
that  were  born  pale  and  debilitated,  and  that  died  a  very  short 
time  after  birth.  This  softening  I  regard  as  a  true  disorganiza- 
tion of  the  mucous  tissue  which  nothing  can  restore ;  the  mem- 
brane, consequently,  is  incapable  of  discharging  its  digestive 
functions,  which  are  of  indispensable  importance  at  the  com- 
mencement of  life,  and  at  an  age  when  nutrition  is  the  dominant 
and  essential  function  of  the  system.  We  should  carefully  guard 
against  confounding  this  softening  with  the  mucus  that  is  often 
spread  over  the  whole  internal  surface  of  the  digestive  tube  of 
infants.  1  would,  therefore,  pronounce  an  infant  non-viable 
where  there  was  found  to  exist  a  universal  and  complete  soften- 
ins:  of  the  internal  membrane  of  the  intestines. 

§  III.  Urinary  apparatus. — Absence  of  a  kidney  can  be  no 
obstacle  to  the  establishment  of  life  ;  neither  can  nephritis  from 
calculi,  which  is  sometimes  found  in  new-born  children  ;  but 
renal  dropsy,  an  affection  that  has  existed  in  infixnts  at  birth,  is 
certainly  a  cause  of  non-viability.  This  species  of  congenital 
dropsy  occurs  in  the  following  manner  :  an  obstruction,  whether 
it  be  stricture  or  obliteration,  exists  in  some  part  of  the  ureters  ; 
in  proportion  as  the  kidneys  are  organized,  the  fluid  which  it  se- 
cretes, finding  no  outlet,  fiows  back  into  the  pelvis  and  infundi- 
buli  of  the  kidney  ;  the  substance  of  the  kidney  becomes  engorg- 
ed and  distended,  and  assumes  the  form  of  an  agglomeration  of 
vessicles— an  arrangement  analogous,  in  every  respect,  to  what 
it  has  at  the  period  of  its  formation  ;  this  vesicular  mass  is  con- 
stantly augmenting;  it  at  last  produces  a  great  distention  of  the 
abdomen,  and  soon  causes  the  death  of  the  child — an  event  of 
necessary  occurrence  with  such  an  infirmity.  This  obstruction, 
instead  of  existing  in  the  ureter,  is  sometimes  found  at  the  neck 
of  the  bladder,  or  at  a  part  near  the  root  of  the  pelvis  ;  under 
such  circumstances,  both  kidneys,  and  the  bladder  itself,  are  dis- 
tended with  fluid.  The  bladder  may  acquire  an  enormous  size, 
and  in  advancing  towards  the  abdomen,  draw  with  it,  out  of  the 
pelvis,  the  contiguous  parts,  dragging  even  the  rectum  from  its 
place,  presenting  that  malformation  which  has  been  described 


524  DISSERTATION    ON    VIABILITY. 

under  the  name  of  coalition  of  the  rectum  with  the  bladder.  An 
infant  thus  affected  is  evidently  not  viable. 

If  the  rectum,  in  adhering  to  the  bladder,  opens  into  it  in  such 
a  manner  that  the  contents  of  the  intestines  find  an  outlet  by  this 
organ,,  viability  will  not  be  impossible.  If  an  obstruction  exist 
in  the  urinary  passages,  accessible  to  the  surgeon,  as  near  the 
gland,  or  in  a  portion  of  the  canal  between  the  root  of  the  penis 
and  the  meatus  urinarius,  so  that,  with  the  aid  of  an  incision,  an 
artificial  hypospadias  can  be  formed,  and  in  this  manner  give  a 
free  passage  to  the  urine,  I  believe  that  then  the  infant  may  be 
regarded  as  viable,  because,  although  affected  with  an  infirmity 
which  is  adverse  to  the  establishment  of  life,  is  not  a  cause  of 
death  which  admits  of  no  remedy.  The  extroversion  of  the 
bladder,  an  affection  always  coexisting  with  a  separation  of  the 
linea  alba,  is  not  necessarily  a  cause  of  premature  death,  since 
individuals  have  been  known  to  live  to  an  age  somewhat  ad- 
vanced with  this  infirmity. 

Inflammation  and  tumefaction  at  the  neck  of  the  bladder  may 
prevent  the  flow  of  urine,  and  cause  a  retention  which  soon  ends 
in  the  death  of  the  child.  This  lesion  must  not  be  lost  sight  of 
in  the  examination  of  the  causes  which  may  determine  the  death 
of  an  infant  whose  viability  is  brought  in  question. 

§  IV.  Peritonitis. — Peritonitis  may  exist  in  new-born  in- 
fants, either  in  an  acute  or  chronic  state  ;  I  have  seen,  in  the 
dead  bodies  of  two  infants,  that  died,  the  one  eighteen  hours,  the 
other  twenty-four  hours  after  birth,  several  old  and  well  organ- 
ized adhesions,  uniting  some  of  the  convolutions  of  the  intes- 
tines ;  one  of  these  infants  was  pale,  small,  and  thin,  the  other 
was  in  the  ordinary  good  condition  of  an  infant  at  birth.  The 
existence  of  these  products  of  phlegmasia  ought  to  be  taken 
into  consideration  when  ascertaining  the  causes  of  an  infant's 
death.  Acute  peritonitis  has  been  several  times  seen  in  infants,  who 
appeared  to  have  brought  the  disease  into  the  world  with  them. 
M.  Duges  has  reported  several  examples  of  this  congenital  affec- 
tion in  his  inaugural  dissertation.  I  have  found  acute  perito- 
nitis in  three  children  that  died  a  short  time  after  birth.  These 
phlegmasiae  are  of  a  nature  serious  enough  to  endanger  the  life 
of  the  child,  but,  as  they  can  be  cured,  they  ought  to  be  arranged 


DISSERTATION    ON   VIABILITY.  525 

among  the  obstacles  of  life,  and  not  among  the  necessary  causes 
of  non-viability. 

Ascitis  may  be  met  with  in  infants  at  birth  ;  the  fluid  which 
distends  the  abdomen  is  in  greater  or  less  quantity.  In  an  infant 
born  dead  there  was  found  nearly  a  pint  of  water  in  the  abdo- 
men, thorax,  and  other  parts  of  the  body  ;  and  what  was  the 
most  singular  in  this  case  was,  that  the  child  was  born  of  a  drop- 
sical mother  [Journal  de  31ed.,  par  A.  Roux.  tome  17,  page  180). 
Dr.  OUivier,  of  Angers,  has  reported  an  instance  of  encysted 
dropsy  in  a  fcetus  born  dead.  Congenital  dropsy  ought  to  be 
considered  as  an  impediment  to  viability,  for  the  abundance  of 
fluid  in  the  abdominal  and  sometimes  in  the  thoracic  cavity,  hin- 
ders, in  a  very  evident  manner,  the  movement  of  the  diaphragm, 
and  the  dilatation  of  the  thoracic  parietes  in  the  act  of  respiration. 

§  V.  Abdominal  hernias. — UmbiUcal  hernia  is  not  mortal ; 
time,  and  proper  surgical  applications,  can  efiect  a  cure,  and 
even  if  they  do  not  succeed,  the  continuance  of  this  infirmity  is 
no  obstacle  to  the  indefinite  prolongation  of  life.  It  is  the  same 
with  congenital  inguinal  hernia  ;  but  when  one  part  of  the  ab- 
dominal viscera  escapes  by  an  opening  in  the  parietes  of  the  ab- 
domen, in  such  a  manner  that  the  liver,  intestines,  and  the  mesen- 
tery are  exposed,  no  doubt  can  exist  in  reference  to  the  non-via- 
bility of  the  child,  which,  if  not  born  dead,  must  soon  expire. 

§  VI.  Respiratory  apparatus. — The  integrity  of  the  res- 
piratory apparatus  in  an  infant  at  birth,  is  one  of  the  first  con- 
ditions of  viability ;  indeed,  it  is  in  this  apparatus  that  the  prin- 
cipal phenomena  occur,  which  establish  the  passage  from  intra- 
uterine to  independent  life ;  it  is  this  which  is  the  source  of  new 
life  to  the  infant,  and  consequently  all  the  lesions  that  are  devel- 
oped in  it  may  endanger  its  existence.  Medical  jurists  only 
admit  infants  to  have  lived  when  they  have  respired ;  for  with 
them  to  respire  is  to  live  ;  it  follows,  therefore,  that  whatever  is 
adverse  to  respiration,  is  likewise  adverse  to  life.  Let  us,  on  this 
account,  examine  with  particular  care  the  congenital  malforma- 
tions and  alFections  of  the  respiratory  apparatus  ;  comprehending, 
in  this  term,  the  nasal  fossae,  larynx,  trachea,  and  lungs.  The 
congenital  malformations  of  the  nose,  the  union  of  the  two  late- 
ral nasal  fossas,  forming  thereby  but  one  cavity,  almost  always 
exist  with  a  malformation  of  the  face  or  cranium,  such  as  mo- 


526  DISSERTATION    ON    VIABILITY". 

nopsia,  anencephalia,  or  hydrocephalia ;  and  experience  proves 
that  a  foetus  so  affected  can  scarcely  live,  only  a  few  moments, 
more  by  reason  of  the  complication  of  these  organic  deviations, 
than  by  the  deformity  of  the  nasal  fossae  ;  this  monstrosity,  there- 
fore, must  be  regarded  as  a  cause  of  non-viability.  The  larynx 
is  habitually  the  seat  of  a  passive  congestion,  more  or  less  com- 
plete, in  infants  at  birth ;  care  must  be  taken  not  to  regard  this 
redness,  which  almost  always  exists  in  this  tube  in  young  infants, 
for  a  phlegmasia:  the  trachea  and  bronchiae  are  very  often  ob- 
structed, by  mucus,  which,  if  it  is  abundant  and  viscid,  opposes 
an  obstacle  to  the  introduction  of  air  into  the  lungs,  and  is  there- 
fore evidently  a  condition  opposed  to  the  establishment  of  life. 
Congenital  inflammation  of  the  larynx  and  of  the  trachea  is 
rarely  seen  ;  I  do  not  know  of  an  authentic  instance  ;  but  if  san- 
guineous congestion  and  accumulation  of  mucus  can  oppose  the 
establishment  of  respiration,  it  is  easily  conceived  that  simple 
phlegmasia,  or  phlegmasia  complicated  with  an  alteration  of  se- 
cretion, occurring  in  the  latter  period  of  intra-uterine  life,  would 
very  considerably  hinder  the  establishment  of  life. 

Congenital  malformations  of  the  lungs  are  not  common,  but 
those  of  the  cavity  of  the  thorax  are  frequently  seen  ;  when  the 
parietes  are  defective,  in  such  a  manner  as  to  expose  the  heart 
and  lungs,  the  child  must  necessarily  perish.  Bianchi  and  Fra- 
cassini  have  given  several  examples,  as  quoted  by  Haller.  In- 
version of  the  right  lung  to  the  left  side,  and  vice  versa,  offers 
no  impediment  to  life.  Congenital  malformation  of  the  thorax, 
which  opposes  a  free  expansion  of  the  lungs,  very  seriously  in- 
fluences respiration,  and  gives  rise  to  symptoms  which  are  con- 
tinued even  to  a  period  far  advanced  in  life,  according  to  an  ac- 
count given  by  M.  Dupuytren ;  but  the  simple  lateral  depres- 
sion of  the  thorax,  while  it  is  the  source  of  some  symptoms,  it 
certainly  is  not  a  cause  of  death.  If  the  malformation  of  the  tho- 
racic parietes  exist  at  the  diaphragm  ;  if,  for  example,  a  perfora- 
tion of  this  muscle  allows  the  abdominal  viscera  to  penetrate  into 
the  cavity  of  the  thorax,  we  can,  without  hesitation,  pronounce 
the  child  non-viable ;  for  it  is  impossible  for  life  to  be  prolonged 
with  such  an  organic  deviation  ;  it  can  only  live  where  a  small 
portion  of  the  organ  has  protruded. 

Inflammation  of  the  pleura,  lungs,  or  bronchiae,  may  take  place 


DISSERTATION    ON    VIABILITY.  527 

before  birth ;  some  authors,  and  among  them  Mauricean,  have 
reported  instances  of  its  occurrence.  I  have  seen,  in  three  infants 
that  died  on  the  first  da^  after  birth,  a  hepatization  of  the  hmo-s, 
sufficiently  advanced  to  cause  the  belief  that,  if  this  hepatization 
had  occurred  during  intra-uterine  life,  it  v/as  at  least  developed 
during  birth,  or  immediately  after  parturition.  Whatever  may 
have  been  the  period  of  its  development,  it  was  evident  that  it  had 
arrested  the  establishment  of  respiration,  and  consequently  caused 
the  death  of  the  child.  I  have  also  found,  in  an  infant  that  died 
some  days  afterbirth,  evident  traces  of  chronic  pleurisy,  which 
doubtless  was  the  cause  of  the  extreme  feebleness  with  which 
this  child  was  affected.  These  facts  should  lead  us  to  the  belief 
that  infants  born  with  congenital  pneumonia  are  not  viable.  It 
is  the  same  with  new-born  children  that  respire  with  greater  or 
less  facility  during  the  first  hours  of  their  existence,  and  where 
pneumonia  or  a  pulmonary  engorgement  supervenes,  drives  out 
the  air  already  introduced  into  the  pulmonary  tissue,  does  not 
allow  it  to  penetrate  anew,  and  in  this  manner  renders  these  or- 
gans unfit  to  discharge  their  functions.  I  have  noticed  several 
facts  in  support  of  this  opinion,  which  have  been  communicated 
to  Professor  Orfila. 

There  is  still  another  circumstance  which  is  adverse  to  the  in- 
troduction of  air  into  the  lungs,  and  which  renders  the  child  in- 
capable of  independent  life ;  I  refer  to  the  extreme  feebleness  of 
the  infant,  and  the  difficulty  with  which  it  dilates  the  thoracic 
parietes,  which,  remaining  almost  immoveable,  do  not  perform 
the  movements  of  inspiration  by  which  the  air  suddenly  passes 
into  the  air-passages  and  penetrates  the  tissue  of  the  lungs.  Not- 
withstanding this  non-existence  of  respiration,  children  may  yet 
live  some  hours,  and  even  days ;  and  if  the  lungs  are  exan)ined 
after  death,  not  the  least  trace  of  air  will  be  found  in  them.  The 
following  example,  which  I  met  with  at  the  Hospice  des  En  fans 
Trouves,  is  in  support  of  what  I  have  asserted.  Three  infants 
born  at  one  birth,  on  the  night  of  the  21st  of  October,  1S26, 
were  brought  immediately  to  the  institution  ;  they  were  all  fee- 
ble, and,  as  it  were,  dying  ;  one  of  them  died  eleven  hours  after 
birth.  The  docimasia  'pidmonwn  was  made  with  the  greatest 
care,  yet  not  the  slightest  trace  of  air  could  be  found  in  the  pul- 
monary tissue  ;  the  lungs  exhibited  nothing  more  than  a  slight 


528  DISSERTATION    ON    VIABILITY. 

sanguineous  congestion  at  their  borders  ;  at  no  point  were  they 
hepatized  ;  therefore  it  was  not  the  presence  of  blood  in  the  cells 
of  the  lungs  which  opposed  the  introduction  of  air ;  but  its  ab- 
sence was  owing  to  the  entire  inability  of  the  infant  to  dilate  the 
thoracic  parietes  in  a  manner  that  would  render  the  lungs  perme- 
able to  the  air. 

It  is  possible,  therefore,  for  an  infant  to  live  without  respiring, 
and  consequently  to  live  without  being  viable ;  this  fact,  which 
we  have  already  demonstrated,  when  considering  certain  con- 
genital malformations  which  of  necessity  result  in  death,  is  here 
exhibited  in  a  new  form.  But  it  should  be  recollected  that  the 
life  of  an  infant  that  does  not  respire  presents  peculiar  signs, 
which  distinguish  it  from  independent  life,  properly  so  called. 
Let  us  examine  these  signs. 

It  is  difficult  to  explain  the  cause  which  sustains  the  precarious 
life  of  an  infant,  that  languishes  for  some  hours  after  birth.  Does 
it  still  live  by  its  embryotic  life  ?  that  is  to  say,  does  the  oxygen- 
ation of  the  blood,  from  its  mixture  with  that  of  the  mother  while 
connected  with  her,  still  continue  for  some  time  to  sustain  exist- 
ence ?  Or  does  the  infant  absorb  a  sufficiency  of  oxygen  by  the 
mucous  surfaces  exposed  to  the  contact  of  the  ambient  air,  to 
enable  this  agent  of  life  to  animate  the  debilitated  being  of  which 
we  are  speaking?  These  are  nice  questions,  and  which  the 
state  of  physiology  at  the  present  day  does  not  enable  us  to  an- 
swer. Be  this  as  it  may,  the  signs  of  life  in  an  infant  where  the 
respiratory  system  cannot  discharge  their  functions  are  confined 
to  the  following :  1st,  The  pulsations  of  the  heart  are  always 
slow,  obscure,  and  irregular.  2d]y,  The  motions  of  the  lips  and 
of  the  limbs  are  very  slow,  and  almost  nothing  ;  the  muscles  of 
the  face  are  immoveable,  or  are  from  time  to  time  pinched,  to 
return  shortly  to  the  state  of  immobihty,  which  imparts  to  the 
physiognomy  its  peculiar  trait  of  destitution  of  expression.  3dly, 
The  cry,  which  in  its  natural  state  is  composed  of  two  distinct 
parts,  the  one  corresponding  with  inspiration,  the  other  with  ex- 
piration, is  here  only  heard  in  one  of  its  parts — that  which 
arises  from  inspiration,  and  consists  of  an  acute  sound,  more 
frequently  smothered,  and  generally  tremulous  and  jerking. 
Lastly,  the  integuments  are  cold  and  livid,  in  place  of  possessing 
the  soft  and  halitous  warmth  so  peculiar  to  infants  at  birth 


DISSERTATION    ON    VIABILITY.  629 

From  such  an  assemblage  of  signs  of  imperfect  life,  it  is,  that 
midwives  and  even  physicians  often  take  their  evidences  of  via- 
bility; and  upon  these  data,  frequently  more  vague  from  their 
incapability  of  appreciating  them,  are  based  their  examinations 
and  their  reports ;  and  judges,  who  are  obliged  to  pronounce 
upon  the  viability  of  an  infant,  upon  whose  life  important  inter- 
ests often  depend,  are  exposed  to  the  hazard  of  declaring  an  in- 
fant viable  that  was  not  so.  We  should  not,  therefore,  be  hasty 
in  pronouncing  upon  the  viability  of  an  infant  from  the  symp- 
toms which  were  observed  during  life,  but  decide  only  after  a 
post  mortem  examination  is  made.  In  vain  would  the  witnesses 
affirm  that  they  saw  the  child  move,  cry,  and  even  attempt  to 
take  the  breast;  if  the  lungs  have  not  been  filled  with  air.,  the 
child  could  not  have  been  viable,  although  it  may  have  lived; 
because  it  had  not  lived  the  extra-uterine  life — viability  con- 
sisting in  the  establishment  of  independent  life,  and  in  the  ab- 
sence of  every  cause  that  may  prevent  its  prolongation.  Neither 
should  a  child  be  considered  as  viable,  that  during  birth  was 
suddenly  attacked  with  pneumonia,  in  consequence  of  which  the 
air  w^as  more  or  less  completely  expelled  from  the  lungs.  There 
then  occurs  a  kind  of  struggle  between  the  attempts  of  nature  to 
establish  life,  and  the  pathological  causes  which  oppose  it.  The 
death  of  the  infant  from  the  first  moment  of  birth  is  the  inevita- 
ble result  of  such  a  disorder. 

If  at  the  end  of  some  days,  after  the  respiration  has  been  fully 
and  regularly  accomplished,  the  child  dies  from  a  phlegmasia 
of  the  pleura  or  lungs,  it  ought  not  on  that  account  to  be  re- 
garded as  non-viable ;  but  the  affection  v/hich  has  supervened 
ought  to  be  taken  into  account,  and  considered  solely  as  being 
adverse  to  the  prolongation  of  extra-uterine  life.  I  have,  in  sev- 
eral instances,  seen  infants  that  at  birth  respired  perfectly  well, 
affected  with  an  hepatization  supervening  in  the  tissue  of  the 
lungs,  by  which  the  air  was  expelled  from  them ;  but  I  never 
saw  both  lungs  so  completely  hepatized  that  no  portion  of  their 
tissue  was  without  air. 

Simple  pulmonary  congestion  without  inflammation  is  equally 

embarrassing  to  the  introduction  of  air  into  the  lungs.     There 

exists  between  respiration  and  circulation  so  close  a  connection, 

that  a  disturbance  of  the  one  will  almost  necessarily  produce  a 

67 


530  DISSERTATION    ON    VIABILITY. 

disturbance  in  the  other.  Some  children  exhibit  at  birth  so 
great  a  sanguineous  turgescence,  that  blood  is  exhaled  in  all 
parts,  and  remains  stagnant  even  in  the  parts  that  are  the  least 
depending.  The  heart,  lungs,  and  liver  are  more  especially- 
affected  with  this  congestion  ;  the  lungs  do  not  then  receive  the 
air  which  the  infant  inspires,  or  at  least  receive  but  a  small  part 
of  it.  Children  born  in  this  condition  have  ordinarily  their  limbs 
osdematous,  and  the  integuments  of  a  violet  hue;  their  movements 
are  slow  and  difficult,  and  their  cry  is  almost  always  stifled.  The 
beatings  of  the  heart  are  obscure,  and  the  pulsations  almost  im- 
perceptible. The  child,  in  a  state  of  sinking  and  prostration, 
languishes  for  some  hours,  or  even  days,  and  at  last  dies.  On 
opening  the  body,  a  small  quantity  of  air  will  be  found  at  the 
anterior  border  of  the  lungs,  the  greater  part  of  which  will  be 
gorged  with  blood,  with  their  surface  emphysematous.  In  such 
a  case,  a  mechanical  obstacle  hinders  the  air  from  penetrating 
the  lungs,  and  death  occurs  from  asphyxia.  An  infant,  born 
and  dying  under  these  circumstances,  cannot  be  pronounced 
viable  ;  for  death  is  the  most  ordinary  consequence  of  this  con- 
genital sanguineous  plethora. 

§  VII.  Circulatory  apparatus. — Congenital  malformations 
of  the  heart  are  not  all  causes  of  non-viability.  An  unusual 
situation  of  this  organ  without  complication,  such  as  the  exist- 
ence of  the  heart  on  the  right  side  of  the  thoracic  cavity  instead 
of  the  left,  is  not  an  obstacle  to  the  establishment  of  life ;  but 
when  it  is  situated  in  the  abdomen,  with  a  deficiency  of  a  greater 
or  less  portion  of  the  diaphragm ;  or  when  the  parietes  of  the 
thorax  are  open,  allowing  of  its  escape  from  its  proper  cavity; 
and  lastly,  when  this  transposition  of  the  centre  of  the  circulatory 
system  is  accompanied  with  an  anencephalia,  or  acephalia,  co- 
incidents not  uncommon,  as  M.  Breschet  has  demonstrated  in 
his  memoir  on  ectopia  of  the  heart,  then  the  infant  cannot  be 
regarded  as  viable.  Absence  of  one  of  the  lateral  portions  of  the 
heart,  so  as  to  leave  as  it  were  a  single  heart,  is  also  opposed  to 
viability.  Dr.  Mauran,  physician  in  Providence,  America,  has 
recently  published  a  case  of  a  heart  having  but  one  auricle  and 
one  ventricle.  The  child  was  affected  with  cyanosis  ;  lived  fif- 
teen days ;  during  which  time  it  was  attacked  with  frequent 
syncopes,  and  threatened  constantly  with  suffocation.    It  perished 


DISSERTATION    ON    VIABILITY.  531 

in  one  of  these  attacks  of  suffocation.  The  separation  of  the 
heart  into  parts,  I  think,  ought  to  be  arranged  among  the  causes 
of  non-viability. 

As  to  the  malformations  which  consist  in  a  narrowness  of  the 
orifices,  or  in  a  deformity  or  incomplete  development  of  the 
valves,  they  present  less  danger  to  the  life  of  a  child  than  the 
preceding  malformations  ;  they  hinder  the  exercise  of  the  regu- 
lar functions  of  the  heart,  and  give  rise  to  some  peculiar  symp- 
toms; but  they  are  not  necessarily  a  cause  of  death,  since  indi- 
viduals are  seen  living  to  a  very  advanced  age  with  such  con- 
genital malformations.  It  is  the  same  with  the  persistence  of 
the  foramen  ovale,  which  is  sometimes  seen  at  an  age  considera- 
bly advanced,  and  which,  although  productive  of  some  serious 
symptoms,  will  not  on  that  account  cause  the  individuals  to 
perish.  I  once  found  a  scirrhous  tumor  in  the  anterior  part  of 
the  left  ventricle.  This  alteration,  I  think,  ought  to  be  consid- 
ered as  a  cause  of  non-viability,  for  it  is  known  that  it  is  the 
character  of  scirrhous  tumors  to  be  always  growing,  and  at  the 
same  time  to  make  rapid  progress.  Now  the  progress  of  these 
tumors  will  inevitably  derange,  or  even  interrupt  the  functions 
of  the  heart  of  the  infant,  if  death  does  not  occur  a  short  time 
after  birth.  Anomalies  in  the  distribution  of  vessels  are  not 
always  a  cause  of  death,  because  no  part  of  the  system  possesses 
greater  facilities  of  supplying  deficiencies  in  the  organs  than  the 
vascular.  The  multiplied  divisions,  communications,  and  rela- 
tions of  the  different  branches  of  an  arterial  trunk,  are  well 
adapted  to  restore  the  course  of  the  blood  through  the  different 
parts  of  the  obliterated  portion.  The  admirable  researches  made 
during  the  last  twenty  years  on  the  subject  of  the  diseases  of  the 
heart  and  bloodvessels,  have  unveiled  to  us,  in  cases  like  these, 
the  great  resources  of  nature. 

The  anatomical  examination  of  the  circulating^  organs  of  an 
infant  at  birth,  show  that  the  passage  from  intra-uterine  to  in- 
dependent life  is  effected  by  transitions  prepared  and  conducted 
in  some  manner  by  nature.  The  obliteration  of  the  foetal  open- 
ings occurs  gradually ;  already  narrowed  at  the  period  of  the 
expulsion  of  the  foetus  from  the  uterus,  they  are  not  entirely 
closed  until  some  days  after  birth,  and  this  gradual  transition 
from  the  form  of  the  foetal  heart  and  vessels  to  their  ordinary 


532  DISSERTATION    ON    VIABILITY. 

form,  is  productive  of  no  symptom  in  the  young  infant;  it  is 
therefore  very  common  to  find  the  foramen  ovale  and  ductus 
arteriosus  open  in  the  child  several  days  after  birth :  this  per- 
sistance  of  the  fostal  openings,  in  the  case  of  the  death  of  a  child, 
must  not  be  considered  as  a  cause  of  its  death  ;  and  if  it  be  not 
complicated  with  some  lesion,  or  other  congenital  malformation, 
the  child  thus  affected  ought  not  to  be  pronounced  non-viable. 
I  once  found  an  aneurism  of  the  arterial  duct  in  an  infant  four 
days  old,  that  during  life  did  not  exhibit  the  least  symptom  of 
such  an  affection.  This  aneurism,  which  was  about  the  size  of 
a  cherry-pit,  contained  a  layer  of  fibrin,  which  had  begun  to 
obliterate  the  canal ;  thus  anticipating,  as  it  were,  the  symptoms 
which  might  have  resulted  from  an  abnormal  obliteration  of  its 
canal. 

Pericarditis  is  sometimes  observed  in  infants  at  birth.  This 
inflammation  is  very  rapid  in  its  progress,  and  very  serious  in  its 
results,  the  child  affected  dying  very  soon  after  it  is  attacked  ;  in 
seven  cases  of  this  disease  which  I  met  with  during  the  year  1826 
at  the  Hospice  des  Enfans  Trouves,  I  found  two  infants  in 
whom  it  had  been  fatal  the  second  day  of  their  birth.  I  once 
found  in  an  infant  of  two  days,  adhesions  between  the  laminae  of 
the  pericardium,  of  so  great  solidity  as  to  warrant  the  belief  that 
they  were  the  product  of  a  former  pericarditis,  developed  during 
the  formation  of  the  foetus.  When  an  infant  dies  from  pericardi- 
tis on  the  day  or  the  day  after  birth,  it  ought,  I  think,  to  be  de- 
clared non-viable,  because  all  circumstances  would  lead  to  the 
belief  that  it  had  brought  the  affection  with  it  from  the  womb, 
and  the  violence  of  the  inflammation  would  necessarily  embar- 
rass and  suspend  the  important  functions  of  the  heart  at  a  period 
when  the  blood  takes  a  new  course,  and  the  centre  of  the  circu- 
lating system  needs  the  assistance  of  additional  activity. 

§VI1I.  Cerebro-spinal  apparatus. — The  cerebro-spinal 
apparatus  is  subject  to  frequent  anomalies;  almost  all  of  them 
cause  the  death  of  the  child ;  these  organs  being  the  centre  of 
hfe,  nothing  can  supply  their  place  when  they  are  wanting  either 
in  whole  or  in  part.  Yet  they  offer  still  different  degrees  of  de- 
formity, according  to  which  the  child  is  more  or  less  viable,  if  I 
may  so  speak — that  is  to  say,  that  these  deviations  of  the  cerebro- 
spmal  apparatus  may  have,  in  certain  cases,  such  an  influence 


DISSERTATION    ON    VIABILITY.  533 

over  the  rest  of  the  system  as  to  determine  promptly  and  neces- 
sarily  the  death  of  the  child,  while  under  other  circumstances  it 
may  live  for  a  length  of  time,  although  affected  with  a  congeni- 
tal malformation  of  the  encephalic  organ.  The  analytical  exam- 
ination of  these  different  cases  will  enable  us  to  understand  their 
difference. 

Complete  acephalia  is  always  a  cause  of  death,  and  requires 
no  comment ;  it  is  the  same  with  anencephalia. 

Anencephalia  consists,  as  is  well  known,  of  absence  of  apart  of 
the  brain  to  a  greater  or  less  extent ;  the  brain  is  imperfect  in 
consequence  of  an  arrest  of  development,  or  of  a  cerebral  or  me- 
ningeal affection,  occurring  during  the  sojourn  of  the  infant  in 
the  womb.  It  is  necessary  to  distinguish  cerebral  atrophia  from 
anencephalia. 

Atrophia,  or  imperfection  of  the  cerebral  mass,  is  no  obstacle 
to  viability.  Children  are  seen  born  with  a  cranium  and  brain 
extremely  small ;  the  forehead  is  sometimes  so  depressed  that  the 
face  assumes  a  peculiar  expression,  having  a  nearer  resemblance 
to  that  of  an  inferior  animal  than  to  the  head  of  a  human  crea- 
ture. Yet  children  affected  in  this  manner  live,  and  exhibit 
nothing  different  from  others,  so  long  as  the  vegetative  life  is  the 
only  one  existing.  Should  they  arrive  at  an  age  when  the  intel 
lectual  faculties  are  developed,  their  intelligence  is  nothing,  or 
almost  nothing,  possessing  scarcely  any  other  consciousness  than 
that  of  their  physical  or  instinctive  wants.  In  a  word,  they  con- 
tinue idiots  during  life;  for  nothing  is  more  common  than  to 
meet  with  a  kind  of  cerebral  atrophia  in  idiots.  In  these  individ- 
uals, says  Georget,  the  forehead  retires  very  obliquely  backward, 
which  gives  to  them  a  great  resemblance  to  the  lower  animals. 
The  cranium  of  an  idiot  is  sometimes  no  more  than  sixteen, 
seventeen,  or  eighteen  inches  in  circumfernce ;  those  of  sixteen 
inches  bear  but  little  resemblance  to  the  human  head.*  I  saw 
at  the  clinical  course  of  M.  Esquirol,  at  the  Salpetriere,  a  plaster 
model  of  a  young  idiot,  the  anterior  part  of  whose  brain  was  so 
flattened  and  depressed  that  it  resembled,  in  every  respect,  that 
of  a  sheep.  At  the  hospital  at  Angers,  I  examined  the  body  of  an 
idiot  that  died  at  the  age  of  fifty  years  ;  the  cranium,  very  much 

*  Dcla  Folic.    Paris,  1820. 


534  DISSERTATION    ON    VIABILITY. 

depressed  at  its  anterior  and  lateral  parts,  arose  in  a  point  towards 
the  occiput ;  the  bones  were  of  remarkable  thickness,  while  the 
brain  was  reduced  to  a  very  small  size ;  the  cerebral  hemi- 
spheres were  two  thirds  smaller  than  what  is  common  in  men  ; 
and  what  is  still  more  remarkable,  the  cineritius  matter  consisted 
of  nothing  more  than  a  thin  lamina ;  the  atrophia  of  this  organ 
appeared  particularly  to  have  occurred  in  this  substance. 

These  diiferent  cases  of  cerebral  atrophia,  which  are  to  be  re- 
garded as  the  first  stage  of  anencephalia,  are  met  with  in  indi- 
viduals that  are  viable,  since  they  have  arrived  at  a  considerably 
advanced  age.  Let  us  observe,  besides,  that  their  viability  is  to 
be  considered  as  referring  to  vegetative  life.  Now,  this  kind  of 
suspension  of  cerebral  evolution,  without  doubt,  hinders  the  de- 
velopment of  the  intellectual  faculties.  But  of  what  importance 
is  it  here  that  the  moral  faculties  remain  fixed  at  the  lowest  de- 
gree of  human  intelligence,  provided  the  conditions  of  vegeta- 
tive life  are  fulfilled  ?  And  viability  so  effectually  exhibits  it- 
self here  in  its  plenitude,  that  individuals  in  whom  cerebral 
atrophy  coincides  with  their  nullity  of  ideas,  often  arrive,  in  the 
course  of  their  life,  at  a  state  of  physical  development  strongly 
in  contrast  with  the  emaciation  and  debility  of  those  feeble  and 
sickly  men,  in  whom  we  admire  the  possession  of  all  that  the 
human  thought  has  of  the  brilliant  and  sublime.  It  is  not  un- 
common to  find,  among  those  men  whose  scientific  or  literary 
productions  have  rendered  illustrious,  beings  so  ill-favored  as 
Pascal  and  Pope.  It  is  well  known  that  the  diminutive  size  of 
Winslow  presented  a  striking  contrast  with  the  strength  of  his 
intellectual  powers. 

The  smallness  of  the  cranium  and  brain  in  infants  that  after- 
wards become  idiots,  is  no  obstacle  to  viability,  which,  considered 
in  the  rigorous  acceptation  of  the  term,  indicates  particularly 
an  aptitude  of  vegetative  or  organic  life. 

But  u'hen  anencephalia  arrives  at  a  stage  much  more  ad- 
vanced than  that  which  we  have  just  described,  the  existence  of 
the  child  is  more  doubtful,  and  it  may  be  said  that  the  degrees 
of  viability  diminish  in  proportion  as  the  brain  becomes  more 
disorganized.  I  found  at  the  Hospice  des  Enfans  Trouves  a 
case  which  exhibits  the  intermediate  stage  between  cerebral 
atrophy,  of  which  we  have  been  speaking,  and  anencephalia 


DISSERTATION    ON    VIABILITY.  535 

advanced  to  the  degree  necessary  to  cause  the  death  of  the  in- 
fant. 

CASE. — On  the  26th  of  January,  1826,  there  was  brought  to 
the  Hospice  des  Enfans  Trouves  a  female  infant  named  Verdelet. 
A  paper  attached  to  the  arm  mentioned  the  age  of  the  child  to  be 
twenty-four  days ;  it  was  of  medium  strength  ;  size  seventeen 
inches  ;  the  integuments  were  purple,  cry  stifled,  thorax  slightly  so- 
norous on  percussion ;  forehead  very  much  sunk,  and  the  parietal 
region  depressed.  From  the  close  approximation  of  the  bones  of  the 
cranium,  there  existed  no  anterior  fontanelle.  At  the  occiput,  about 
the  lambdoidal  suture,  there  was  a  blunt  projection.  The  eyes  pro- 
jected outside  of  the  orbit,  the  superior  borders  of  which  were 
depressed.  The  head,  inclined  backward,  and  the  face  directed 
upward,  gave  to  the  physiognomy  of  this  infant  the  peculiar  expres- 
sion of  anencephalia.  This  child  died  on  the  11th  of  February,  with- 
out presenting  any  other  symptom  than  those  pointed  out  above. 
Upon  a  post  mortem  examination,  the  lungs  were  found  hepatized  at 
their  summit  and  posterior  border.  The  foramen  ovale  was  still  open, 
but  the  ductus  arteriosus  was  obliterated.  The  cranial  vault  and 
the  posterior  portion  of  the  vertebrae  being  removed,  the  medulla 
spinalis  was  found  perfect  throughout  its  whole  extent ;  the  corpora 
pyramidalia  and  corpora  olivaria  were  very  much  developed.  In 
examining  the  brain  from  behind  forward,  the  pons  varolii,  tubercula 
quadrigemina,  infundibulum,  tuber  cinereum,  the  pituitary  gland 
and  commissure  of  the  optic  nerves,  were  found  in  their  normal 
state.  The  distinction  between  the  posterior  and  middle  lobes  was 
well  marked  ;  but  the  anterior  lobe  could  scarcely  be  recognized, 
and  instead  of  presenting  a  slightly  convoluted  and  furrowed  surface, 
there  was  nothing  to  be  seen  but  two  reddish  eminences  about  the 
size  of  a  filbert,  separated  from  each  other  by  a  slightly-marked  di- 
vision, but  reunited  posteriorly  by  the  anterior  commissure;  at  the 
anterior  part  there  did  not  appear  the  fossa?  in  which  are  lodged  the 
olfactory  nerves  ;  but  they  were  blended  posteriorly  with  the  cere- 
bral substance,  from  which  they  were  separated  anteriorly,  and  their 
terminations  reflected  on  themselves  and  rounded,  were  attached  to 
the  lateral  apophysis  of  the  cristi  galli.  When  the  brain  was  exam- 
ined superiorly,  the  posterior  part  of  the  hemispheres  was  found  de- 
veloped as  in  the  natural  state ;  but  the  convolutions  were  suddenly 
interrupted  in  the  anterior  part  of  the  brain,  and  ceased  in  the  direc- 
tion of  a  line  which  would  be  in  continuation  of  the  fissure  of  Syl- 


536  DISSERTATION    ON    VIABILITY. 

vius.  The  superior  and  anterior  part  of  the  brain  was  consequently 
wanting  altogether.  There  did  not  exist  any  corpus  callosum  ;  the 
posterior  commissure  was  the  only  vestige  of  it.  There  was  no 
septum,  consequently  the  anterior  part  of  the  lateral  ventricles  was 
exposed.  Immediately  before  the  interruption  of  the  convolutions, 
there  was  a  depression,  in  which  was  found  a  membranous  pouch, 
enclosing  a  small  quantity  of  citron-colored  serum,  formed  probably 
from  the  pia  mater  and  tunica  arachnoidea,  which  were  filled  with 
vessels.  This  pouch  had  no  external  opening.  When  cut  longitu- 
dinally, two  small  olive-shaped  eminences  were  exposed,  separated 
by  a  deep  furrow,  and  upon  which  were  two  white  bandalettes,  uni- 
ted anteriorly  in  the  form  of  a  V,  and  separating  posteriorly,  so  as  to 
extend  below  the  interrupted  convolutions.  These  were  the  rudi- 
ments of  the  fornix.  Between  these  bands  an  interval  was  left, 
which  is  usually  occupied  by  the  septum  lucidum.  The  anterior 
projections,  rugous  and  irregular,  were  evidently  formed  by  the  tha- 
lami  nervorum  opticorum,  the  internal  borders  of  which  constituted 
the  third  ventricle,  communicating  largely  with  the  lateral  ventricles 
by  means  of  the  fornix,  below  which  was  seen  the  tela  choroidea. 
On  each  side  of  the  fornix  was  seen  the  posterior  extremity  of  the 
plexus  choroides.  When  the  posterior  portion  of  the  cerebral 
hemispheres  was  removed,  the  lateral  ventricles  were  seen  to  be 
continued  behind,  spread  and  form  as  usual,  the  ancyloid  cavity. 
Behind  the  thalami  optici  the  corpora  striata  could  scarcely  be  dis- 
tinguished, but  some  pulpous  matter  presented  a  few  traces  of  them  ; 
the  cerebellum  was  perfect. 

The  vessels  from  the  vertebral  and  carotid  arteries  were  distrib- 
uted at  the  base  of  the  cranium,  in  the  accustomed  manner. 

One  of  the  principal  branches  of  the  carotid  was  directed  towards 
the  point  corresponding  with  the  fifth  ventricle,  and  sent  branches 
which  lost  themselves  between  the  convolutions,  and  others  spread 
over  the  surface  of  the  membranous  pouch  of  which  I  have  spoken. 
All  the  nerves  of  the  base  of  the  brain  were  in  their  points  of  origin 
and  disposition  perfectly  normal.  The  base  was  slightly  depressed 
in  its  lateral  parts,  so  that  the  anterior  fossae  were  much  less  devel- 
oped than  the  middle  and  posterior. 

I  have  reported  this  case  in  detail,  to  show  that  an  infant  can 
live  a  longtime  with  the  absence  of  some  one  of  the  parts  which 
constitute  the  encephalic  mass.  The  form  of  the  cranium  cor- 
responded with  the  deformity  of  the   brain,  and   it  might  be 


DISSERTATIOX    ON    VIABILITY.  537 

thought  that  the  brain  of  this  child  was  analogous  to  those  of 
the  idiots  of  which  we  have  spoken  ;  but  there  not  only  existed 
in  this  case  an  atrophy  of  the  organ,  but  likewise  an  absence  of 
several  portions  which  enter  into  its  composition.  This  advanced 
stage  of  anencephalia  ought  to  be  regarded  as  a  cause  of  non- 
viability.  This  infant  lived  without  being  viable  ;  that  is  to  say, 
without  exhibiting  the  organic  conditions  which  are  indispen- 
sable to  a  prolongation  of  independent  life. 

Deformity  of  the  cranium  does  not  always  exist  in  conjunction 
with  congenital  malformations  of  the  brain.  M.  Breschet  has 
given  several  instances  of  well-formed  crania,  containing  a  mu- 
tilated and  incomplete  brain.  To  the  facts  with  which  he  has 
enriched  science  I  can  add  the  following  case. 

CASE. — Noblet,  agf;d  three  days,  a  male,  entered  the  Hospice 
des  Enfans  Troiives  on  the  11th  of  March,  1826.  During  his  con- 
tinuance in  the  hospital  he  cried,  sucked  his  thumb,  and  took  the 
breast  of  the  nurse.  He  was  examined  on  the  twelfth,  and  directed 
to  be  sent  to  the  country  on  the  next  day,  but  died  during  the  night. 
The  post  mortem  examination  was  made  on  the  succeeding  day  ;  the 
child  exhibited  exteriorly  a  good  condition  ;  several  livid  marks 
were  upon  the  body.  Follicular  ulcers  were  found  in  the  stomach, 
and  there  was  a  general  congestion  of  the  intestinal  tube.  The  lungs 
were  healthy  and  crepitating. 

The  cranium  presented  a  very  strongly-marked  development ;  but 
when  opened  was  found  to  be  filled  with  a  membranous  pouch,  cov- 
ered with  a  number  of  vessels,  and  filled  with  a  fluid  having  the  ap- 
pearance and  color  of  the  white  of  an  egg.  It  was  easy  to  discover 
that  this  pouch  was  formed  of  the  pia  mater  and  arachnoidea.  As 
soon  as  it  was  pierced,  the  liquid  matter  flowed  out  upon  a  mass  of 
cerebral  substance,  at  the  base  of  the  cranium,  of  which  I  shall  pres- 
ently give  a  description.  The  medulla  spinalis  was  perfect ;  the 
corpora  pyramidalia  and  corpora  olivaria  were  fully  developed ;  the 
cerebellum  was  well  formed;  the  pons  varolii  also  presented  its 
usual  size  and  form,  but  the  anterior  cornua  gave  rise  to  four  pro- 
jections, two  on  the  left  and  two  on  the  right  side  ;  the  internal  ones 
appeared  to  be  be  the  vestiges  of  the  thalami  optici,  and  were  sepa- 
rated by  an  interval  which  in  a  healthy  state  would  have  constituted 
the  third  ventricle.     The  two  others  appeared  to  be  the  vestiges  of 

the  corpora  striata ;  they  were  partly  covered  by  a  membranous  fold 

68 


538  DISSERTATION    ON    VIABILITY. 

which  appeared  to  be  the  plexus  choroides.  Lastly,  outside  of  the 
parts  described  there  was  found  a  pulpy  mass,  flattened  and  very 
soft,  and  which  without  doubt  represented  the  rudiments  of  the  two 
cerebral  hemispheres.  These  two  portions  of  cerebral  substance 
were  confounded  with  the  internal  surface  of  the  meninges,  which 
was  found  covered  with  the  pulpy  appearances  very  analogous  to 
the  substance  of  the  brain.  When  the  inferior  surface  of  this  rudi- 
ment of  brain  was  examined,  the  olfactory  nerves  were  found  to 
exist  only  in  the  form  of  thin,  fragile,  medullary  filaments.  The 
commissure  of  the  optic  nerves  was  scarcely  visible ;  the  nerves  at 
the  place  where  they  arose  were  almost  nothing,  while  in  the  orbit 
they  possessed  their  usual  development.  All  the  other  nerves  at  the 
base  of  the  brain  were  developed  in  the  ordinary  manner.  The 
arteries  furnished  by  the  carotid  and  the  basilar  trunk  of  the  ver- 
tebral artery,  had  their  usual  distribution,  and  their  branches  were 
sent  to  the  walls  of  the  pouch  formed  of  the  meninges.  There  were 
therefore  wanting  in  this  brain,  1st,  the  entire  two  hemispheres;  2dly, 
the  corpus  callosum ;  3dly,  the  fornix ;  4thly,  the  lateral  ventricles  ; 
5thly,  tela  choroidea ;  6thly,  the  anterior  and  posterior  commissures. 

If  the  cranium  of  this  child  had  not  been  opened,  the  cause 
of  its  death  would  not  have  been  suspected,  and  perhaps  it  would 
have  been  pronounced  viable.  Life  was  maintained  during  the 
three  days  by  the  nervous  influence  of  the  medulla  oblongata, 
which  the  organic  deviation  did  not  affect. 

It  is  not  necessary  to  demonstrate  the  non-viability  of  an  anen  • 
cephalous  foetus,  where  the  cranium  is  destroyed  and  perforated ; 
it  is  well  known  that  such  a  one  can  exist  but  a  few  hours. 

I  ought  to  point  out  apoplexy  of  new-born  infants  as  a  cause 
of  death,  and  particularly  the  general  softening  of  the  brain, 
which  is  sometimes  found  in  young  infants,  mixed  with  thick- 
ened blood,  and  diffusing  a  strong  odor  of  sulphuretted  hydro- 
gen, indicating  evidently  the  decomposition  of  the  organ. 

Hydrocephalia  is  not  a  cause  of  non- viability,  except  when  the 
cranium  is  of  a  great  size,  and  the  fontanelles  are  widely  spread. 
In  this  case,  the  cerebral  ventricles  are  inordinately  distended, 
and  their  walls  softened  and  disorganized.  Encephalocele, 
which  sometimes  accompanies  dropsy  of  the  brain,  likewise  ren- 
ders the  existence  of  the  infant  too  precarious  to  allow  us  to  ex- 
pect it  to  live  :  encephalocele,  without  hydrocephalia,  is  not  ne- 


DISSERTATION    ON    VIABILITY.  639 

cessarily  a  cause  of  death :  M.  Lallemand  found  a  hernia  of  the 
cerebellum  in  an  aged  woman  at  Salpetriere.  But  when  hydro- 
cephalia  only  exists  with  an  enlargement  of  the  cranium,  and 
especially  when  the  fontanelles  are  but  slightly  enlarged,  it  may 
be  reasonably  expected  that  the  child  will  live  even  to  an  ad- 
vanced age.  Camper  has  observed  that  hydrocephalic  infants 
will  live  so  much  the  longer,  as  the  bones  of  the  cranium  are 
more  approximated,  and  their  sutures  are  more  solid  :  sometimes 
hydrocephalia  is  really  an  obstacle  to  viability.  Meningitis, 
which  supervenes  sometimes  immediately  after  birth,  and  which 
produces  convulsions,  is  not  a  cause  of  death  in  all  the  infants 
aifected  with  it;  it  should  not,  therefore,  be  regarded  as  absolutely 
mortal.  Fractures  of  the  cranium  are  not  serious  except  from 
their  complications.  Congenital  malformations  of  the  medulla 
oblongata  are  always  fatal ;  hydrorachis,  complicated  with  spi- 
na bifida,  is  not  always  to  be  considered  as  a  fatal  affection. 
And  indeed  when  the  integuments  of  the  tumor  are  perfect,  the 
child  may  arrive  at  quite  an  advanced  age ;  the  progress  of  ossi- 
fication may  even  lead  to  a  perfect  cure  ;  but  when  the  tumor  is 
ulcerated,  death  is  inevitable. 

Congenital  malformations  of  the  genital  organs,  such  as  im- 
perforation  or  absence  of  the  vagina,  are  without  doubt  very  seri- 
ous, but  are  not  mortal  in  infants  at  birth  ;  and  death  may  not 
even  occur  at  the  period  of  puberty,  since  the  menstrual  evacua- 
tion has  occurred  from  other  surfaces  than  that  which  ordinarily 
secretes  it ;  consequently  we  ought  not  to  regard  infants  as  in- 
capable of  living,  that  are  affected  with  these  congenital  malfor- 
mations. 

Fractures,  luxations,  or  divisions  of  the  limbs,  are  not  causes 
of  non-viability. 

The  various  cases  of  duplicate  monstrosity,  either  by  inclusion 
or  coalition,  cannot  be  submitted  to  general  rules  ;  but  it  is  ne- 
cessary to  examine  each  case  by  itself,  to  appreciate  properly  the 
degree  of  viability  of  infants  affected  with  this  species  of  mon- 
strosity. 

I  shall  here  terminate  the  analytical  examination  which  I 
proposed  to  make  of  congenital  malformations  and  diseases 
affecting  the  principal  organs  of  an  infant  at  birth.  Let  us  now 
see  what  are  the  inferences  which  may  be  drawn  from  this  analysis. 


540  DISSERTATION    ON    VIABILITY. 


PART  SECOND. 

MEDICO-LEGAL  INDUCTIONS. 

The  question  of  viability,  in  medical  jurisprudence,  presents 
itself  in  several  points  of  view :  sometimes  there  is  required 
from  the  physician  different  investigations,  according  to  the  in- 
formation necessary  to  be  obtained.  Should  infanticide  be  the 
question  at  issue,  it  will  be  necessary  to  ascertain,  1st,  whether 
the  infant  was  full  grown  ;  2dly,  whether  it  was  born  living ; 
3dly,  whether  it  was  viable ;  4thly,  whether  it  had  lived.  If, 
on  the  contrary,  the  questions  to  be  decided  refer  to  grants  or 
testamentary  discussions,  the  question  of  viability  will  present 
itself  in  a  different  form;  for  there  are  almost  always  two 
parties  opposed,  the  one  maintaining  that  the  infant  lived  and 
was  viable,  and  the  other  assuming  the  contrary ;  and  it  will  be 
necessary  in  the  first  place  to  show  whether  the  infant  had  lived. 
Verbal  testimony  and  the  docimasia  pulmonum  will  ascertain 
this  point.  If  the  child  had  not  lived,  and  should  the  assertions 
of  witnesses  be  contradictory,  the  physician,  on  ascertaining  that 
there  was  not  the  least  trace  of  air  in  the  lungs,  ought  to  dis- 
continue any  further  investigations,  for  the  question  is  settled  by 
this  fact ;  and  in  vain  will  it  be  alleged  that  the  infant  had 
respired,  and  that  pneumonia  had  supervened  and  had  driven  the 
air  from  the  lungs  ;  and  although  we  have  before  demonstrated 
that  the  development  of  pneumonia  before  birth,  or  during  the 
establishment  of  respiration,  ought  to  be  considered  as  a  cause 
of  non-viability,  yet  the  physician  could  not  conscientiously 
affirm  that  the  infant  had  lived,  since  he  was  not  in  possession 
of  incontestable  evidence  of  it ;  moreover,  it  is  very  rare  for 
pneumomia  to  drive  out  all  the  air  contained  in  the  lungs. 

If  a  small  quantity  of  air  be  found  in  the  lungs,  and  the  attes- 
tation of  witnesses  is  in  favor  of  the  life  of  the  infant,  the  phy- 
sician, before  pronouncing  upon  its  viability,  ought  to  examine 
whether  the  signs  of  life  spoken  of  are  not  analogous  to  those  which 
we  have  already  remarked  as  manifested  in  those  infants  where 


DISSERTATION    ON    VIABILITY.  541 

the  respiration  is  incomplete  and  irregular ;  if  such  be  the  case, 
he  must  declare  the  infant  not  to  have  been  viable,  and  that  it 
had  not  been  in  full  possession  of  independent  life.  Lastly,  even 
when  all  the  signs  of  independent  life  exist  in  an  incontestable 
manner,  it  will  still  be  necessary  to  be  well  assured  that  there  is 
no  congenital  malformation,  nor  any  serious  lesion  in  any  organ 
essential  to  life :  thus,  for  example,  an  infant  may  respire  well, 
but  if  affected  with  an  obliteration  of  the  intestinal  tube  must 
necessarily  perish  ;  consequently  cannot  be  reputed  viable. 

Death  arising  from  congenital  affections  takes  place  at  ex- 
tremely variable  periods ;  a  non-viable  infant  may  live  eight, 
ten,  or  fifteen  days,  as  we  have  seen  in  a  subject  where  the 
heart  was  single,  and  that  died  fifteen  days  after  birth  :  a  child 
may  also  perish  from  a  disease  the  nature  of  which  is  not  neces- 
sarily opposed  to  viability,  on  the  day  of  birth  or  the  day  after. 
Consequently  the  principle  ought  not  to  be  laid  down,  as  has 
been  done  by  Professor  Chaussier,  that  every  infant  attacked 
with  a  disease  in  the  uterus,  that  dies  within  twenty-four  hours 
after  birth,  whatever  be  the  cause,  should  be  reputed  non-viable. 
(Chaussier,  Memoire  medico-legal^  adresse  a  M.  le  garde-des- 
sceaux.)  Indeed,  on  the  one  hand,  all  diseases  that  are  devel- 
oped in  the  fostus  in  the  womb,  are  not  essentially  mortal ;  and 
on  the  other,  the  diseases  essentially  mortal  which  the  infant 
brings  with  it  at  birth,  do  not  always  cause  death  within  twenty- 
four  hours  after  birth. 

The  indispensable  conditions  then  of  viability,  considered 
with  reference  to  the  anatomy,  physiology,  and  pathology  of  the 
foetus,  I  conceive  to  be  as  follows  : 

1st,  The  child  ought  to  be  born  at  the  full  time  :  2dly,  No 
physical  or  pathological  obstacle  should  exist  adverse  to  the  es- 
tablishment of  respiration  and  independent  circulation:  3dly, 
When  respiration  and  circulation  are  established,  the  body  of 
the  foetus  should  present  no  monstrosity,  no  congenital  disease 
capable  of  causing  death  sooner  or  later.  Now  the  examination 
of  these  particular  lesions  deserves  especially  to  fix  our  attention, 
as  by  considering  them  we  will  be  able  often  to  cause  truth  to 
triumph,  whether  the  question  be  to  establish  the  fact  that  the 
child  had  not  lived,  or  to  demonstrate  the  contrary.  In  order 
properly  to  appreciate  these  lesions,  it  has  appeared  to  me  expe- 


542  DISSERTATION    ON    VIABILITY. 

dient  to  divide  them  into  separate  classes,  according  to  their  im- 
portance :  the  one  being  essentially  mortal ;  others  embarassing 
the  development  of  life,  without  being  essentially  a  cause  of  non- 
viability;  and  the  last  offering  no  opposition  to  the  establishment 
of  life  :  thus,  an  infant  born  with  an  obliteration  of  the  oesopha- 
gus, is  not  viable ;  another  coming  into  the  world  with  gastritis, 
or  cutaneous  phlegmasia,  may  live ;  another  bringing  with  it  a 
fracture  of  one  of  the  limbs,  or  hare-lip,  is  unquestionably  viable. 
This  distinction  is  of  the  greatest  importance ;  for  those  born 
with  infirmities  or  diseases  of  the  first  order  will  admit  of  no 
discussion  upon  their  viability ;  those  of  the  second  order  may 
be  extenuating  circumstances  in  questions  of  infanticide  ;  those 
of  the  third  order  can  never  be  considered  as  causing  non-via- 
bility. 

In  order  to  render  the  data  upon  the  question  of  viabiUty 
more  positive,  it  would  be  desirable  that  a  commission  of  en- 
lightened physicians  should  cause  a  view  of  congenital  dis- 
eases, arranged  according  to  the  distinctions  which  have  been 
advanced,  to  be  drawn  up ;  this  tabular  view,  founded  on  ana- 
tomical and  pathological  principles,  might  serve  as  a  base  to 
magistrates  and  physicians  to  judge  of  the  viability  of  an  infant, 
when  it  is  necessary  to  show  the  relative  value  of  some  congen- 
ital disease,  in  order  to  prove  whether  the  child  was  viable  or 
not. 

I  have  subjoined  a  table  of  this  kind,  which  doubtless  some 
one  better  qualified  than  myself  might  correct  with  advantage, 
and  which  will  not  be  considered  of  as  much  importance  as  if  it 
were  examined  and  discussed  by  a  commission  of  intelligent 
physicians. 

TABULAR  YIEW  OF  CONGENITAL  DISEASES, 

WHICH     MAY    BE    CONSDERED    AS    HAVING    AN     INFLUENCE    ON 
THE    QUESTION   OF    VIABILITY.* 

Order  I. — Congenital  malformations  and  diseases  necessarily 

w,ortal. 

Absence  of  the  skin,  with  imperfection  in  the  parietes  of  the 
splanchnic  cavities.     (Eventration.) 

*  See  Appendix,  page  601. 


DISSERTATION    ON    VIABILITY.  543 

Obliteration,  division  or  duplication  of  the  oesophagus. 

Ulcers  and  gelatinous  softening  developed  in  this  organ  before 
birth. 

Obliteration  of  the  stomach. 

Its  gelatinous  softening  developed  before  birth. 

Obliteration  and  division  of  the  superior,  middle,  and  a  third 
part  of  the  inferior  portion  of  the  digestive  canal. 

General  softening  of  the  intestinal  mucous  membrane  devel- 
oped before  birth. 

Dropsy  of  one  or  both  kidneys. 

Coalition  of  the  obliterated  rectum  with  the  bladder. 

Deformity  of  the  nasal  fossae  with  monopsia. 

Hernia  of  the  abdominal  organs  into  the  cavity  of  the  thorax. 

Inflammation  of  the  pleura,  lungs,  or  bronchia,  before  or 
during  birth. 

Impossibility  of  dilating  the  thoracic  parietes,  from  extreme 
debility  of  the  child.    (Feebleness  of  birth.) 

Congestion  of  the  heart  and  lungs  at  the  time  of  birth. 

A  single  heart,  or  that  consists  of  but  one  auricle  and  one 
ventricle. 

Division  of  the  heart  into  two  parts  by  a  complete  separation. 

Pericarditis  developed  during  intra-uterine  life. 

Acephalia. 

Anencephalia. 

Congenital  malformation  of  the  medulla  spinalis. 

Hydrocephalus,  with  deformity  of  the  cranium. 

Encephalocele,  with  hydrocephalia. 

Apoplexy,  complicated  or  not  with  fracture  of  the  cranium- 
occurring  before  or  at  birth. 

Softening  of  the  brain. 

Hydrorachis,  with  ulceration  of  the  tumor. 

Order  II. — Congenital  malformations  and  diseases,  which, 

without  being  necessarily  m^ortal,  may  he  adverse  to  the  es- 

tablishment  of  independent  life. 

Ecchymoses,  contusions,  sanguineous  tumors,  and  cyanopo- 
thia. 

Naevi  materni  very  much  developed. 

Cutaneous  inflammations. 


644  DISSERTATION   ON   VIABILITY. 

Adhesion  of  the  hps. 

Inordinate  length  of  the  tongue. 

Extreme  narrowness  of  the  oesophagus. 

Simple  oesophagitis. 

Follicular  ulcers  in  the  stomach. 

Simple  strictures  of  the  intestines. 

Imperforation  of  the  anus. 

Intestinal  hemorrhage. 

Calculous  nephritis. 

Peritonitis,  with  or  without  dropsy. 

Congenital  malformation,  or  depression  of  the  thoracic  pari- 
etes. 

Communication  to  a  greater  or  less  extent  of  the  auricles  or 
ventricles  of  the  heart. 

Hydrocephalia  but  little  advanced,  and  without  a  separation 
of  the  bones  of  the  cranium. 

Imperforation  and  absence  of  the  vagina. 

Accumulation  of  mucus  in  the  bronchiae. 

Order  III. — Congenital  malformations  and  diseases  not  ad- 
verse to  viability. 

Simple  absence  of  the  skin. 
Cutaneous  excrescences. 
Excessive  development  of  the  pilous  system. 
Albinism. 

Stationary  naevi  materni. 
Hare-lip. 

Division  of  the  velum. 

Deviation  of  the  stomach,  transposition  of  the  abdominal  vis- 
cera. 
Absence  of  one  of  the  kidneys. 
Hypospadias. 

Extroversion  of  the  bladder. 
Umbilical  and  inguinal  hernia. 
Transposition  of  the  heart. 
Stricture  of  its  orifices,  anomalies  of  the  valves. 
Persistance  of  the  foetal  openings  for  some  days  after  birth. 
Cerebral  atrophy. 


DISSERTATION    ON    VIABILITY.  545 

Hydrorachis,  without  ulceration  of  the  tumor. 
Fractures,  luxations,  and  divisions  of  the  limbs. 

If  this  tabular  view  were  discussed  and  properly  digested  by 
physicians,  and  sanctioned  by  law,  it  would  be  desirable  to  es- 
tablish the  following  rules  relative  to  viability  considered  with 
reference  to  the  pathology  of  new-born  children  : 

1st,  No  child  shall  be  considered  viable  that,  having  respired, 
is  affected  with  a  disease  mentioned  in  the  first  order. 

2dly,  Every  child  born  with  a  disease  comprised  in  the  second 
order  shall  be  considered  as  viable,  but  affected  with  a  lesion 
that  embarasses  life. 

3dly,  Every  child,  having  respired,  that  is  affected  solely  with 
a  disease  indicated  in  the  third  order,  shall  in  every  instance  be 
considered  viable.* 


APPENDIX 

BY    THE    TRANSLATOR 


SEPARATION    OF    THE    CORD. 

Note  to  page  30. 

We  can  scarcely  coincide  with  the  opinion  that  the  separation  of 
the  cord  arises  from  mechanical  causes ;  the  phenomenon  or  appear- 
ances of  inflammation  are  of  still  too  frequent  occurrence  upon  the 
separation  of  the  cord,  to  attribute  it  to  these  causes. 

The  conclusions  to  which  the  author  arrives,  from  the  circum- 
stances he  notices,  as  to  the  desiccation  of  the  cord,  will  be  admitted 
as  tenable  in  a  large  majority  of  cases;  it  nevertheless  would  be 
scarcely  safe  in  medico-legal  discussions,  to  place  so  complete  a 
reliance  on  them ;  they  can  only  be  considered  as  strong  corrobo- 
rative testimony  as  to  the  previous  life  or  death  of  the  child. 

HEMORRHAGE    FROM    THE    CORD. 

Fatal  hemorrhage  from  the  cord  will  sometimes  take  place  from 
the  slipping  of  the  ligature.  This,  however,  can  scarcely  ever  occur, 
except  from  great  carelessness  ;  although  it  may  happen  where  the 
cord  is  (Edematous  and  of  unusual  size,  and  even  when  precautions 
are  taken  to  prevent  so  unfortunate  an  event.  A  case  of  this  kind 
occurred  to  the  writer.  The  cord  was  (edematous  and  of  great  size ; 
three  ligatures  were  successively  applied,  and  each  drawn  very  tight, 
and  the  attention  of  the  nurse  particularly  directed  to  its  condition. 
The  child  falling  asleep,  no  further  thought  was  bestowed  on  it  by 
the  attendants,  until  the  low  moaning  of  the  infant  caused  the  nurse 
to  take  it  up,  when  the  clothes  were  found  filled  with  blood.  The 
ligatures  upon  the  cord  were  completely  loosened,  from  the  constant 
oozing  of  the  fluid  from  its  extremity.  The  infant  was  cold  and 
pulseless ;  the  face  purple  and  shrivelled ;  and  it  died  in  about  an 
hour  after  the  discovery  of  the  hemorrhage. 


548  APPENDIX. 

It  is  well  known  to  practical  observers,  that  a  fatal  hemorrhage 
may  also  arise  from  the  umbilicus,  from  ulceration  rapidly  occurring 
at  the  cord  ;  and  further,  that  independently  of  the  loss  of  blood,  the 
disordered  changes  which  occasionally  occur  from  suppurative  irri- 
tation at  the  navel,  may  prove  destructive  to  the  life  of  the  child 
several  days  after  birth. 

When  hemorrhage  takes  place  from  ulceration,  a  compress,  with 
an  astringent,  such  as  powdered  alum,  should  be  applied  ;  and  in  case 
of  failure  of  this  means,  it  has  been  usual  to  recommend  the  actual 
cautery,  escharotics,  and  the  application  of  a  ligature  to  the  vein. 
But  compression  is  probably  the  best  method  of  arresting  the 
hemorrhage  ;  and  as  a  compress  cannot  always  be  depended  on, 
pressure  with  the  finger  is  undoubtedly  the  best;  and  where  it  is 
necessary  to  continue  it  for  a  length  of  time,  it  may  be  done  by 
changing  the  assistants  at  proper  intervals. 

When  ulceration  occurs  at  the  navel,  a  gently  astringent  wash 
will  be  found  to  be  the  best  application  ;  if  there  be  much  inflammation, 
a  poultice  of  slippery-elm ;  and  if  it  become  gangrenous,  a  weak 
solution  of  chloride  of  soda  will  be  the  remedies  indicated. 

SIZE    AND    WEIGHT    OF    NEW-BORN    CHILDREN. 
Note  to  page  37. 

The  average  length  of  male  children  is  greater  than  that  of  female. 
Roeder  found  the  length  of  sixteen  male  children  to  be  20|f  inches, 
and  of  eight  female,  20-i^.  Soemmering  states  the  most  rapid  in- 
crease of  the  foetus  takes  place  during  the  first  week  of  conception, 
and  that  it  does  not  proceed  in  the  same  ratio  ;  but  that  it  is  retarded 
in  the  second  month,  accelerated  in  the  third,  again  retarded  in  the 
fourth,  accelerated  again  in  the  sixth,  and  once  more  retarded  to  the 
end  of  the  ninth  month. 

It  ought  to  be  remembered  that  the  EngHsh  inch  is  1.065977 
Paris  inch. 

Dr.  Hunter  states  that  several  thousand  new-born  and  perfect 
children  were  weighed  at  the  British  hospitals,  by  Dr.  McCauley, 
and  the  smallest  found  to  be  4,  and  the  largest  11  pounds.  Of  60 
male  and  60  female  children,  weighed  by  Dr.  Clark,  the  lightest 
weighed  4,  and  the  heaviest  10  pounds  :  average,  7  pounds  10  ounces. 
Of  26  weighed  by  Roeder,  the  heaviest  weighed  8,  and  the  lightest 
5^-  pounds  :  average,  8  pounds  6  ounces.  (See  Dr.  Gordon's  article 
in  the  Supplement  to  the  Encyclopedia  Brittanica.) 

In  7,077  cases  at  the  Hospice  de  la  Matermite,  at  Paris,  the  average 


APPENDIX. 


649 


weight  of  the  children  at  birth  was  found  to  be  a  little  more  than  6 
pounds  ;  the  smallest  weighing  1^  pounds,  and  the  heaviest  10^.  In 
a  note  in  Beck's  Medical  Jurisprudence,  it  is  mentioned  that  the 
following  results  were  obtained  from  1,541  children  who  were 
weighed  at  birth,  and  who,  with  the  exception  of  8  or  10,  appeared 
to  have  attained  the  full  term : 


2  pounds 

and  some  ounces 

3 

(( 

.       4 

(( 

5 

u 

6 

(6 

7 

(( 

8 

(( 

9 

(( 

(( 

3 
31 
17 

308 
606 
380 
100 
16 

1541 


There  is  recorded  in  the  3d  volume  of  the  Medical  and  Physical 
Journal,  the  case  of  a  child  that  weighed  17  pounds.  The  Lancet 
for  December,  1838,  contains  the  account  of  a  child  born  dead,  that 
weighed  17  pounds  12  ounces.  On  the  other  hand,  children  have 
been  born  exceedingly  small,  and  displaying  all  the  phenomena  of 
life.  A  case  occurred  in  this  city,  in  the  practice  of  Dr.  Thomas 
Boyd,  where  the  child,  at  the  age  of  6  weeks,  weighed,  with  all  the 
clothes,  but  2^  pounds.  He  is  now  living,  and  an  ordinary-sized 
man.  Dr.  Wendell,  of  Brooklyn,  informed  me  of  two  still  more 
remarkable  instances :  one  where  the  child,  born  at  the  full  time, 
weighed  1  pound  9  ounces;  it  lived  5  months,  and  then  died  of  croup. 
Another,  that  weighed  at  birth  but  1  pourid,  and  who  lived  5  weeks, 
and  died  of  diarrhoea.  The  mother  of  this  child  gave  birth  to  four 
children,  the  largest  of  whom  weighed  but  4  pounds. 

In  twins,  the  average  weight  of  each  is  stated  to  be  less  than  that 
of  single  children,  although  their  combined  weight  is  greater.  Dr. 
Clark  found  the  average  weight  of  12  twins  to  be  11  pounds  a  pair; 
the  heaviest  weighed  13,  and  the  lightest  8|-  pounds.  Mr.  BurnSj 
however,  states  that  he  has  known  instances  in  which  each  twin  was 
rather  above  than  under  the  usual  weight. 

The  French  pound  mentioned  in  the  text,  contains  9216  Paris 
grains,  while  the  English  avoirdupois  pound  contains  only  8532.5 
Paris  grains,  and  one  pound  avoirdupois  contains  435,25  grammes. 
The  smallest  weight,  therefore,  recorded  by  the  author,  is  2  pounds 


550  APPENDIX. 

13  ounces  and  4  drachms  ;  and  the  largest,  the  correctness  of  which 
he  justly  questions,  is  upwards  of  27  pounds  avoirdupois.  The 
average  of  5  to  5|  pounds  is  here  mentioned  as  the  weight  of  chil- 
dren at  birth ;  corresponding  to  a  little  more  than  5^  to  nearly  6 
pounds.  The  other  experiments  in  the  French  hospitals  likewise 
show  the  weight  in  French  pounds,  poids  de  marc ;  therefore,  the 
average  of  a  little  over  6  pounds  stated  above,  in  this  note,  corres- 
ponds to  something  over  6|  pounds  avoirdupois.  Dr.  Dewees 
mentions,  as  the  result  of  his  experience,  that  the  average  weight  is 
a  little  more  than  7  pounds  ;  from  which  it  would  appear  that  children 
in  this  country,  at  birth,  are  larger  than  in  France.  The  remark  of 
Dr.  Dewees,  however,  cannot  be  considered  any  thing  more  than  an 
approximation  to  the  truth,  for  want  of  the  extensive  opportunities 
of  observation  enjoyed  in  the  French  hospitals. 

MONSTROSITY. 
Note  to  page  64. 
A  case  of  monstrosity  is  recorded,  accompanied  with  a  plate,  by 
Dr.  Duane,  in  the  American  Journal  of  the  Medical  Sciences  for 
February,  1830,  caused  by  an  injury  which  the  mother  had  received 
from  frequent  kicks  on  the  abdomen,  by  her  husband.  She  had 
previously  borne  three  children,  at  three  successive  accouchements, 
all  perfectly  formed.  The  monster  caused  by  these  injuries  was  of 
the  Cyclops  order ;  it  uttered  no  cry,  nor  did  it  move  its  limbs  ;  a 
feeble  inspiration  and  spasmodic  contraction  of  the  muscles  of  the 
face  were  the  only  symptoms  of  life  it  exhibited.  "  The  eye  was 
situated  at  about  the  usual  commencement  of  the  middle  nasal 
suture  ;  it  was  oblong ;  its  horizontal  diameter  about  one  inch ;  its 
perpendicular  diameter  about  half  an  inch  ;  the  conjunctiva  extended 
about  one  line  transversely  over  the  cornea  superiorly,  and  bounded 
it  inferiorly ;  the  cornea  had  the  shape  of  two  circles  joined  on  one 
side  ;  there  were  two  distinct  pupils."  "  The  chest  was  somewhat 
distorted.  The  penis  was  three  quarters  of  an  inch  long ;  the  testes, 
with  the  scrotum  and  its  raphe,  were  wanting.  The  arms  were 
unusually  long,  hanging  down,  when  the  body  was  suspended,  an 
inch  and  a  half  below  the  knees.  The  lower  extremities  were  small, 
bent  at  the  knee,  and  anchylosed."  Dissection  revealed  a  great 
derangement  and  confusion  of  parts  ;  among  others,  there  was  no 
trace  of  muscles  on  the  abdomen  or  lower  extremities,  their  place 
being  supplied  by  adipose  matter. 


APPENDIX.  551 

CONGENITAL    SMALLPOX. 

Note  to  page  80. 

That  the  foetus  is  sometimes  infected  with  smallpox,  is  a  fact  esta- 
blished by  a  number  of  well  authenticated  cases.  Dr.  Pearson  has 
recorded  in  Duncan's  Commentaries,  vol.  xix.,  a  number  of  cases  of 
this  kind  which  he  has  collected  from  various  sources,  and  he  also 
mentions  one  which  fell  under  his  own  notice.  The  Memoirs  of 
the  Lond.  Med.  Soc,  vol.  iv.,  contains  an  account  of  a  lady  who, 
in  the  7th  month  of  her  pregnancy,  was  innoculated  and  went  through 
the  regular  smallpox.  She  was  delivered  of  a  dead  child,  covered 
with  pustules  that  proved  to  be  variolous,  from  their  having  commu- 
nicated the  smallpox  to  several  persons  who  were  innoculated  with 
some  of  the  matter.  (See  Dissertation  on  the  Pathology  of  the 
Human  Fluids,  by  Jacob  Dyckman,  M.  D.,  N.  Y.,  1814,  p.  186, 
where  reference  is  made  to  cases  by  Bland,  Derham,  Roberts,  Hay- 
garth,  Burzerius,  Laird,  Forbes,  Jenner,  and  others.) 

Two  instances  of  the  effects  of  variolous  contagion  upon  the  preg- 
nant mother  and  child,  occurred  in  the  practice  of  Dr.  Hosack.  (See 
Observations  on  Mercury,  by  J.  W.  Francis,  M.  D.,  Amer.  Med.  and 
Philosoph.  Register,  vol.  iv.,  p.  479.) 

The  editor  also  mentions,  in  a  note  in  Denman's  Midwifery,  3d 
Amer.  edit.,  p.  313,  that  he  has  seen  smallpox  eruptions  in  a  new- 
born infant,  the  mother  of  whom  labored  under  varioloid,  which 
prevailed  in  New-York  in  1823-4. 

ERYSIPELAS. 

Note  to  page  101. 

Infantile  erysipelas  is  a  disease  of  very  rare  occurrence  in  this 
country,  but  is  more  frequently  seen  in  Europe,  particularly  in  public 
hospitals.  The  writer  has  met  with  but  few  cases,  and  those  in  dis- 
pensary practice,  some  few  years  since.  In  these  instances  there 
existed  a  high  degree  of  vascular  excitement,  attended  with  evident 
derangement  of  the  biliary  and  digestive  organs.  Where  such 
symptoms  clearly  exist,  the  first  step  in  the  treatment  is  to  evacuate 
the  bowels  by  a  mercurial  purgative,  followed  by  a  teaspoonful  of 
castor  oil ;  a  soluble  state  of  the  bowels  and  a  relaxed  condition  of 
the  skin  should  then  be  preserved  by  the  use  of  small  doses  of 
ipecacuanha  combined  with  calomel,  or  a  solution  of  acetate  of 
ammonia ;  and  if  there  be  acidity  present,  the  use  of  bicarbonate  of 


552  APPENDIX. 

soda  or  potas,  may  be  added  to  the  former.  In  robust  children, 
where  there  is  a  high  state  of  excitement,  topical  depletion  will  be 
found  to  be  of  great  utility.  Various  methods  of  effecting  this  have 
been  recommended.  Mr.  Brodie  and  Mr.  Lawrence  advise  extensive 
incisions,  Dr.  Babington  short  incisions  or  punctures,  while  Mr. 
Travers  is  in  the  habit  of  using  leeches.  When  they  are  used,  they 
ought  always  to  be  applied  to  the  healthy  skin.  Two  cases  of  fatal 
hemorrhage,  where  free  incisions  were  used,  are  reported  in  one  of 
the  English  journals  a  few  years  since,  occurring  in  infants  from  the 
inattention  of  the  nurse.  When  there  exists  great  tension,  which  it 
is  necessary  to  relieve  promptly,  free  incisions  would  probably  be 
the  proper  manner  of  accomplishing  it ;  and  the  ill  consequences 
which  might  arise  may  be  guarded  against  by  careful  attention  on 
the  part  of  the  nurse. 

In  this  disease  the  most  opposite  remedies  have  been  recommended. 
While  depleting  means  are  used  by  some,  stimulants  are  employed 
by  others.  Mr.  Burns  recommends  am.monia  in  large  doses.  Dr. 
Underwood  bark  and  aromatic  confection ;  but  the  propriety  of  these 
remedies  may  well  be  doubted,  when  there  exists  any  vascular 
excitement.  Do  not  these  opposite  opinions  arise  from  too  limited 
a  view  of  the  nature  of  the  disease,  and  from  not  considering  it  as 
consisting  of  different  stages — that  of  violent  excitement  and  cor- 
responding collapse  ?  These  changes  often  occur  suddenly,  and  at 
very  uncertain  intervals,  and  on  this  account  may  have  appeared  to 
require  remedies  of  a  very  different  nature,  and  may  indeed  demand 
some  change  of  treatment  in  a  very  short  space  of  time  ;  the  disease, 
therefore,  needs  the  closest  discrimination  in  the  adaptation  of  thera- 
peutic agents  to  the  existing  constitutional  symptoms. 

Desault  has  recommended  emetics,  and  Dr.  Eberle  thinks  that 
emetic  doses  of  ipecacuanha  would  often  prove  serviceable  in  the 
early  stages  of  infantile  erysipelas,  from  having  seen  active  vomiting 
produced  by  the  use  of  calomel  and  ipecacuanha,  on  the  third  day  of 
the  disease,  followed  by  an  immediate  amendment. 

As  a  local  remedy,  mercurial  ointment  has  been  used  with  success : 
it  should  be  applied  to  the  whole  of  the  inflamed  part,  and  on  a 
portion  of  the  surrounding  skin  ;  and  in  case  of  vesication,  the 
vesicles  should  be  opened  and  the  fluid  discharged  before  its  appli- 
cation. In  obstinate  cases,  blisters  are  of  the  greatest  efficacy  when 
applied  to  the  margin  of  the  inflammation.  They  appear  to  operate 
by  changing  the  action  of  the  bloodvessels,  and  also  probably  by 
depleting  from  the  capillaries  in  inflamed  portions  of  the  skin.     In  a 


APPENDIX.  553 

case  attended  by  the  writer,  the  progress  of  the  inflammation,  which 
was  on  the  abdomen,  was  speedily  arrested  by  applying  a  long  strip 
of  blistering  ointment  along  the  edge  of  the  sound  skin. 

MEASLES. 
Note  to  page  102. 

This  disease  is  very  much  modified  during  its  prevalence  as  an 
epidemic,  by  the  peculiarity  of  the  constitution  of  the  individual 
attacked ;  for  it  often  exists  in  every  variety  and  degree  of  intensity, 
among  children  exposed  to  the  same  influence.  The  state  of  the 
atmosphere,  and  the  season  of  the  year,  also  controls  its  develop- 
ment in  a  very  remarkable  manner,  the  symptoms  being  always  more 
mild  in  summer,  and  more  violent  in  the  cold  and  changeable  weather 
in  winter. 

It  is  often  nothing  more  than  a  disease  of  simple  excitement,  with 
catarrhal  symptoms — which,  indeed,  are  its  invariable  attendants — 
and  mild  aperients  and  demulcents,  with  pediluvia,  will  for  the  most 
part  be  all  the  treatment  necessary.  Infusions  of  flaxseed,  slippery- 
elm,  or  barley  water,  will  be  found  sufficient  to  manage  this  disease 
in  its  mild  form. 

Still,  as  the  slight  excitement  may  increase,  no  one  being  able  to 
foretel  the  continuance  of  the  same  condition,  the  physician  should 
be  prepared  to  meet  it  in  all  its  forms,  whether  of  increased  vascular 
excitement,  or  of  local  inflammation,  or  congestion.  When  the  former 
of  these  conditions  arises,  the  use  of  diaphoretic  medicines,  combined 
with  an  expectorant,  are  clearly  indicated.  Syrup  of  ipecacuanha, 
either  alone  or  combined  with  a  solution  of  extract  of  liquorice,  or 
syrup  of  tolu,  is  a  good  combination  for  fulfilling  this  indication. 
As  a  general  rule,  ipecacuanha  is  to  be  preferred  to  antimony,  in 
very  young  children;  for  the  debilitating  effects  of  the  latter  are 
sometimes  truly  alarming,  and  have  even  been  fatal.  Two  instances 
of  fatal  prostration  in  young  infants  have  come  to  my  knowledge, 
which  ensued  immediately  upon  the  administration  of  a  small  quan- 
tity of  antimonial  wine.  Still,  great  benefit  is  derived  from  the 
cautious  use  of  very  minute  doses  of  this  medicine,  in  high  ex- 
excitement  occurring  in  robust  children.  A  grain  of  tartar  emetic 
in  a  half  pint  of  water,  of  which  a  teaspoonful  may  be  given  once 
in  two,  three,  or  four  hours,  will  be  the  best  method  of  ascertaining 
the  effect  of  this  medicine  on  an  infant,  and  it  may  be  increased  or 
diminished,  as  the  child  is  capable  of  bearing  its  action. 

Upon  the  appearance  of  decidedly  inflammatory  symptoms  in  any 

70 


554  APPENDIX. 

of  the  viscera,  sanguineous  depletion  must  be  adopted,  to  be  propo^ 
tioned  to  the  degreee  of  inflammation  and  constitutional  vigor  of  the 
child.  There  is  scarcely  a  disease  which  requires  the  loss  of  blood 
more  than  measles,  when  the  lungs  are  inflamed,  and  it  is  the  most 
eff'ectual  means  of  preventing  the  troublesome  and  often  serious 
cough,  which  is  one  of  the  sequela  of  this  affection.  A  hoarseness 
contracted  early  in  life  often  continues  to  adult  age,  and  the  founda- 
tion of  phthisis  frequently  has  its  commencement  in  an  attack  of 
measles. 

In  slight  cases  of  inflammation,  or  should  there  rest  any  obscurity 
on  the  complication,  producing  a  doubt  as  to  the  propriety  of  gen- 
eral bloodletting,  local  bleeding  will  be  both  safe  and  useful.  A 
large  warm  poultice  may  then  be  applied  to  the  chest.  Emetics  are 
often  highly  necessary  to  relieve  the  child  from  the  accumulation  of 
the  serous  fluid  so  copiously  efl'used  in  the  air-passages,  when  the 
lungs  are  inflamed  or  congested.  Throughout  the  disease  the  bow- 
els should  be  kept  open  by  the  use  of  mild  aperients. 

The  brain  is  sometimes  seriously  affected,  showing  itself  in  a 
drowsiness,  from  which  it  is  difficult  to  arouse  the  patient,  and  the 
quantity  of  mucus  closing  the  nostrils  produces  a  kind  of  stertor- 
ous breathing  ;  an  open  condition  of  the  bowels,  stimulating  baths 
to  the  lower  extremities,  will  for  the  most  part  be  sufficient  for  the 
relief  of  this  symptom.  If,  however,  there  should  appear  much 
heat  about  the  head,  leeches  will  be  necessary,  followed  by  a  blister 
between  the  shoulders. 

When  there  exists  any  visceral  inflammation,  blisters  are  undoubt- 
edly of  great  efficacy,  after  the  arterial  action  is  in  some  degree  sub- 
dued. In  young  children,  however,  they  ought  to  be  left  on  but  a 
short  time,  and  never  suflJiered  to  remain  until  the  part  is  blistered, 
as  very  obstinate  ulcers  have  been  the  effect  of  this  practice.  The 
skin  should  be  examined  from  time  to  time,  by  raising  the  corner  of 
the  plaster ;  and  if  a  considerable  redness  be  observed,  the  blister 
must  then  be  removed,  and  the  part  dressed  with  simple  cerate, 
which  will  be  sufficient  to  raise  the  cuticle.  I  have  never  seen  an 
ill-conditioned  ulcer  produced  where  these  precautions  were  taken. 

The  cough  is  often  exceedingly  annoying  after  the  inflammatory 
symptoms  have  been  removed  ;  this  is  best  treated  by  opiates,  and 
the  acetate  of  morphine  combined  with  syrup  of  squills  is  one  of  the 
best  forms  in  which  they  can  be  administered. 

It  sometimes  happens  that  the  eruption  is  slow  in  appearing  ;  the 
face  is  pale  and  shrunk,  and  a  difficulty  of  respiration  or  profound 


APPENDIX.  555 

Stupor  exist.  In  this  congestive  form  every  effort  should  be  made  to 
restore  action  to  the  circulating  system  ;  and  stimulating  frictions, 
warm  baths,  and  blisters  freely  used  to  effect  this  object ;  while  local 
bleeding  from  the  congested  part  may  be  necessary.  The  same 
means  ought  likewise  to  be  resorted  to  in  cases  of  retrocession  of  the 
eruption.  In  addition  to  these,  warm  and  stimulating  drinks  are  re- 
commended by  Armstrong,  Eberle,  and  others ;  and  camphor  or  am- 
monia, suspended  in  a  mucilaginous  fluid,  are  also  advised  by  them. 

SCARLET     FEVER. 
Note  to  page  106. 

The  author  has  referred  to  the  various  phlegmasiae  for  details  of 
the  proper  treatment  of  this  disease  when  complicated  with  inflam- 
mation of  different  organs,  and  from  which  alone  it  acquires  its  vio- 
lent and  fatal  symptoms,  with  the  remark  that  inflammation  of  the 
throat  is  of  all  others  the  complication  the  most  common.  Upon 
consulting  the  history  of  the  various  phlegmasiae,  and  particularly 
the  chapter  on  inflammation  of  the  throat,  it  will,  I  think,  appear 
evident  that  a  knowledge  of  scarlatina,  as  it  has  of  late  appeared  in 
this  country,  can  scarcely  be  obtained  from  these  sources.  It  will 
therefore  be  made  the  subject  of  a  few  observations. 

It  is  a  remark  of  Dr.  Armstrong,  in  his  valuable  dissertation  on 
this  subject,  that,  so  far  as  his  observation  extended,  inflammation  of 
the  throat  constantly  attended  the  cutaneous  affection  ;  and  I  think, 
upon  close  examination,  it  will  always  be  found  to  exist  in  connex- 
ion with  the  eruption,  although  sometimes  indeed  in  a  very  slight  de- 
gree. Not  only  is  the  throat  inflamed,  but  the  inflammation  extends  to 
the  other  parts  of  the  mucous  surface,  but  lessening  as  this  membrane 
becomes  more  removed  from  the  influence  of  the  external  air ; 
the  membrane  lining  the  cavity  of  the  mouth,  fauces,  pharynx,  and 
trachea — the  latter  being  very  remarkably  affected  in  infants — are, 
in  connexion  with  the  skin  and  cellular  tissue  beneath  it,  as  is  evi- 
dent from  the  general  tumefaction  of  the  body,  the  seat  of  the  dis- 
ease. All  anatomical  facts  go  to  the  establishment  of  the  fact,  now 
generally  admitted,  of  the  identity  of  the  cutaneous  and  mucous  sur- 
faces. M.  Billard  has  given  a  striking  illustration  of  this,  in  record- 
ing the  simultaneous  congestion  of  the  skin  and  mucous  membrane 
in  nearly  two  hundred  infants  ;  clearly  proving  these  surfaces  to  be 
influenced  by  the  same  physiological  laws,  and  thus  establishing 
their  mutual  identity.  The  disposition  of  that  portion  of  the  diges- 
tive passages  which  is  exposed  to  the  influence  of  the  external  air  to 


556  APPENDIX. 

become  inflamed  more  readily  and  in  a  peculiar  manner,  has  also 
been  noticed  by  the  author. 

Scarlatina  is  more  especially  manifested  in  the  external  and  in- 
ternal dermoid  surfaces  ;  and  besides  the  probable  cause  of  its 
appearance,  as  above  suggested,  in  the  upper  part  of  the  digestive 
mucous  membrane,  there  exists  another  reason  which  will  explain, 
I  think,  the  violent  inflammation  of  the  tonsils.  These  organs  are 
not  strictly  glands,  but  are  the  continuation  of  the  mucous  membrane, 
and  are  nothing  more  than  a  congeries  of  mucous  follicles,  thus  con- 
taining a  great  extent  of  mucous  surface  in  a  small  compass  ;  hence 
the  greater  inflammation,  secretion,  and  tumefaction,  analogous  to 
the  more  abundant  eruption  in  the  folds  of  the  skin  about  the  joints. 

In  addition  to  the  reasons  already  assigned  for  the  more  frequent 
appearance  of  the  inflammation  in  the  fauces,  there  appears  to  be  a 
different  predisposition  to  the  disease  in  different  portions  of  the  mu- 
cous surface  at  certain  periods  of  life  ;  and  in  young  infants  the 
trachea  is  the  part  most  seriously  affected.  In  them  the  secretion 
from  the  mucous  membrane  of  the  trachea  is  often  immense,  and 
the  danger  of  suffocation  imminent,  from  the  viscid  mucus  clogging 
the  air-passages  to  the  lungs,  and  also  by  obstructing  the  free  flow  of 
blood  from  the  brain,  and  thus  producing  a  congestion  of  that  organ. 

That  the  disorder  exists  internally,  is  evident  from  the  gastro- 
pulmonary  mucous  membrane  pouring  out  the  abundant  secretion  so 
common  in  violent  cases  of  the  disease,  even  where  autopsic  exami- 
nation reveals  little  or  no  capillary  injection  or  ulceration  in  the 
mucous  membrane  of  the  stomach  and  intestines. 

Dissections  show  that  although  marks  of  inflammation  have  often 
been  found  in  the  stomach  and  intestines,  sufficient  to  prove  the  ex- 
tension of  the  inflammation  throughout  the  mucous  surface,  yet  their 
occurrence  is  much  less  frequent  in  those  parts,  in  infants,  than  in 
the  fauces,  oesophagus,  trachea  and  lungs :  and  although  effiision  is 
almost  always  found  in  the  brain  in  those  children  who  have  died 
from  scarlatina, — the  closing  scene  for  the  most  part  being  attended 
with  symptoms  of  congestion  and  effusion, — yet  the  greatest  func- 
tional and  organic  derangement  is  more  frequently  found  to  exist  in 
the  fauces  and  trachea.  Whether  the  brain  is  implicated  or  not,  the 
throat  and  trachea  always  manifest  inflammation  and  often  great  ul- 
ceration, particularly  where  depletion  was  neglected  at  the  com- 
mencement of  the  disease.  But  in  an  affection  arising,  as  this  does, 
from  a  specific  contagion,  and  in  which  the  whole  capillary  system 
appears  to  be  in  a  state  of  erethism,  and  often,  upon  a  sudden  inva- 


APPENDIX.  557 

sion,  manifesting  itself  only  in  a  prostration  of  nervous  energy,  it  is 
an  error  to  insist  upon  localizing  it,  and  considering  certain  organs 
and  tissues  as  its  exclusive  seat.  The  older  physicians,  close  ob- 
servers of  morbid  phenomena  as  they  appear  during  life,  but  less 
versed  it  is  true  in  special  anatomy — which  it  must  be  admitted  will 
sometimes  limit  our  view  of  diseases  to  the  part  alone  which  retains 
the  traces  of  sanguineous  turgescence  or  disjrganization  after  death- 
termed  such  diseases  "  morbi  totius  substantias. " 

After  a  careful  examination  of  the  writings  of  the  various  authors 
on  this  disease,  and  from  the  experience  afforded  by  the  late  epidem- 
ics, the  conclusion  is  irresistible  as  to  its  specific  and  contagious  char- 
acter. I  know  that  the  fact  of  its  contagiousness  has  been  denied, 
and  the  opposite  opinion  ably  advocated  by  respectable  authority. 
But  there  is  a  tendency  to  extremes  on  all  subjects,  and  to  lose  sight 
of  facts  of  daily  occurrence  when  the  mind  is  engaged  in  generalizing, 
and  when  any  important  discovery  is  made  which  promises  to  eluci- 
date that  which  before  was  obscure,  or  by  assigning  as  a  cause  a 
gratuitously-assumed  principle.  To  what  else  can  be  attributed  the 
opinion  held  by  some  physiologists,  that  the  syphilitic  disease  is  not 
contagious  ? 

Scarlet  fever  prevails  at  all  seasons,  but  the  winter  and  spring 
appear  to  be  most  favorable  to  its  development  and  dissemination. 
Great  irregularity  exists  as  to  the  times  of  its  appearance  and  the 
severity  of  its  attack,  but  the  peculiarity  of  atmosphere  that  exercises 
this  infl  7ence  is  unknown.  For  the  most  part,  it  prevails  as  an  epi- 
demic, and  assumes  different  degrees  of  intensity,  from  the  simple 
rash  on  the  skin,  or  efflorescence  of  the  fauces,  of  a  very  limited  du- 
ration, to  the  most  malignant  form,  with  all  its  train  of  frightful  and 
fatal  symptoms.  No  age  is  exempt  from  the  scourge ;  it  however 
prevails  mostly  among  children  ;  and  in  the  epidemic  which  prevail- 
ed in  the  city  of  New  York  in  1837,  in  579  deaths  from  this  disease, 
125  were  between  the  age  of  1  and  2  years,  and  72  under  1  year. 

Authors  have  made  three  species  of  this  disease;  but  as  they  often 
pass  into  each  other,  and  the  line  of  separation  cannot  always  be  dis- 
tinctly marked  during  the  prevalence  of  an  epidemic, — the  S.  sim- 
plex sometimes  continuing  a  day  with  great  mildness,  and  of  a  sud- 
den assuming  the  form  of  the  anginose  variety,  and  the  S.  anginosa 
in  its  turn  presenting  every  variety,  from  a  red  and  slightly-tumefied 
appearance  of  the  fauces,  palate,  tonsils  and  uvula,  to  the  ulceration 
and  sloughing  of  these  parts  and  the  congestion  of  the  various  vis- 
cera,— it  appears  to  be  of  more  practical  importance  to  view  it  as  a 


658  APPENDIX 

disease  of  different  degrees  of  severity,  and  to  be  ready  to  meet  it 
under  all  its  forms,  be  the  attack  of  ever  so  mild  a  character.  To 
this,  the  most  usual  manner  of  its  appearance,  may  be  added  the 
congestive  form  of  its  invasion  ;  distinguished  by  the  paleness  of  the 
surface  and  the  want  of  reaction. 

It  has  been  already  remarked  that  all  parts  of  the  mucous  tissue 
are  not  equally  disposed  to  be  affected  with  the  inflammation  produced 
by  this  disease ;  and  the  various  local  congestions,  either  of  the  brain, 
stomach,  fauces,  trachea,  or  lungs,  will  of  course  require,  together 
with  other  complications,  in  many  cases,  a  difference  of  treatment, 
and  will  call  into  action  the  judgment  of  the  physician  ;  and  indeed 
there  does  not  exist  a  disease  where  there  is  greater  difficulty  in 
laying  down  a  precise  course  of  treatment,  and  in  which  the  exercise 
of  a  sound  judgment  is  more  necessary,  than  in  a  disease  so  greatly 
complicated  as  scarlet  fever.  There  has  been  generally  too  indis- 
criminate a  reliance  on  one  course  of  treatment,  whatever  be  the 
stage  or  symptoms  of  the  disease. 

Upon  the  treatment  of  this  disease,  a  practical  writer  in  Dr. 
Doane's  edition  of  Good's  Study  of  Medicine,  makes  the  following 
truly  judicious  remarks  :  "  The  treatment  must  be  regulated  by  many 
concurring  circumstances  ;  in  its  simplest  form,  it  is  almost  super- 
erogation to  interpose  art,  where  nature  is  so  judicious  in  her  opera- 
tions ;  in  other  cases,  mild  aperients,  sudorifics,  simplicity  in  diet, 
and  attention  to  cleanliness,  may  often  suffice.  In  its  complex  form, 
with  sore  throat,  our  indications  are  of  a  more  discriminating  order, 
and  challenge  our  severest  judgments  and  most  effective  capabilities. 
A  difference  in  pathological  opinions  must  necessarily  lead  to  a 
corresponding  difference  in  our  curative  means  ;  as,  for  instance, 
whether  we  deem  the  existing  state  of  disordered  action  to  depend 
mainly  upon  the  asthenic  or  sthenic  diathesis,  upon  debility  or 
increased  energy.  Too  exclusive  an  adherence  to  either  belief  has 
been  a  prolific  source  of  evil ;  the  practice  of  viewing  scarlatina  as  a 
disease  of  debility,  has  induced  many  to  recommend  early  bark,  wine, 
alcohol,  and  the  diffusible  stimuli,  with  cordial  nourishment,  after  the 
method  of  the  older  alexipharmic  prescribers,  and  to  deprecate  all 
antiphlogistic  medicines.  After  this  manner,  in  order  to  support  the 
strength,  have  many  epidemical  or  pestilential  disorders  at  various 
periods  been  treated  ;  I  need  not  add  with  what  pernicious  results. 
On  the  other  hand,  without  due  consideration  of  the  specific  character 
of  scarlet  fever,  of  the  laws  which  regulate  febrile  infection,  and  o^ 
the  uniform  influence  which  diseases  of  such  origin  have  in  their 


APPENDIX.  559 

tendency  to  induce  a  greater  expenditure  of  the  vital  powers,  other 
prescribers  have  urged,  even  in  the  advanced  state  of  the  complaint, 
the  antiphlogistic  method,  by  copious  bleedings,  emetics,  drastics, 
cold  effusion,  and  other  potent  agents,  on  the  ground  that  all  the 
morbid  phenomena  depended  upon  an  active  inflammatory  diathesis. 
Of  the  consequences  of  such  a  pathology,  we  have  too  many  fatal 
examples." 

While  the  disease  is  simple,  a  mild,  antiphlogistic  treatment  will 
be  all  that  will  be  required.  But  however  mild  the  disease  may  at 
first  appear,  it  should  be  carefully  watched,  and  upon  the  appearance 
of  any  increase  of  inflammatory  action  about  the  throat,  or  of  any 
symptoms  of  oppression,  as  the  progress  of  the  disease  is  often 
rapid,  more  active  measures  will  become  necessary ;  and  regarding 
the  disease  as  aflfecting  principally  the  capillary  system,  an  emetic 
will  be  found  the  proper  remedy  to  break  up  this  general  and  deeply- 
rooted  affection,  by  its  powerful  action  on  that  system  ;  the  effect  of 
the  operation  of  which  is  to  prevent  congestion,  by  the  restoration 
of  the  secretory  functions  of  the  various  organs.  Authors  in  every 
country,  who  have  written  on  this  disease,  bear  testimony  to  the 
powerful  efficacy  of  emetics  at  the  commencement.  They  may, 
therefore,  be  regarded  as  a  most  valuable  remedy.  This  should  be 
followed  by  a  mild  purgative  and  warm  bath ;  and  if  there  be  much 
febrile  excitement,  it  must  be  met  by  the  use  of  diaphoretics,  such 
as  small  doses  of  ipecacuanha,  together  with  demulcent  drinks  and 
tepid  effusion.  The  cold  eflusions  of  Dr.  Currie  appear  only  appli- 
cable in  the  simple  form  of  the  disease,  where  there  is  little  or  no 
local  inflammation.  The  bowels  should  be  kept  open  by  mild  ape- 
rients, or  injections. 

If  the  febrile  action  continue,  or  symptoms  of  cerebral  or  other 
local  congestion,  or  severe  inflammation  of  the  fauces  ensue,  blood 
must  be  taken,  either  with  the  lancet,  or  by  leeches  applied  to  the 
affected  part,  according  to  the  urgency  of  the  symptoms,  and  the 
condition  of  the  patient.  Every  symptom  shows  a  high  state  of 
inflammatory  action.  The  skin  is  intensely  inflamed,  the  fauces  are 
in  the  same  condition,  the  tonsils  are  loaded  with  blood  and  exces- 
sively tumefied,  and  the  occasional  formation  of  abscesses  in  the 
joints  also  prove  the  previous  existence  of  inflammation  in  these  parts. 
With  all  these  evidences  of  inflammation,  bloodletting  in  some 
form,  then,  appears  to  be  the  most  rational,  as  it  is  the  most  efficient, 
remedy ;  and  I  must  bear  testimony  to  the  efficacy  of  this  remedy, 
both  general  and  local,  in  this  stage  of  the  disease.     The  application 


560  APPENDIX. 

of  leeches  to  the  throat  is  indispensable,  and  will  often  be  sufficient 
to  relieve  the  congestion  of  these  parts,  particularly  if  followed  by 
a  poultice.  In  severe  cases,  reliance  ought  not  to  be  placed  on 
leeches  alone,  but  general  bloodletting  must  be  used  early  in  the 
disease  ;  for  it  is  the  deferring  of  this  remedy  a  few  hours  beyond 
its  proper  time,  that  has  brought  the  remedy  into  disrepute.  Blisters 
to  the  throat  have  been  highly  recommended  by  Dr.  Rush  and  others, 
but  I  have  not  found  much  advantage  from  their  use. 

If  there  be  much  prostration,  warm  fomentations,  stimulating 
cataplasms,  or  dry  cups,  should  be  applied  over  the  congested  parts, 
and  small  doses  of  calomel  will  be  found  useful  in  cases  of  local 
congestion.  An  early  and  decided  bleeding,  however,  on  the  ap- 
pearance of  violent  inflammatory  symptoms  of  the  throat,  followed 
by  mercurial  purgatives,  are  necessary  to  prevent  the  progress  of 
the  inflammation  ;  and  it  is  surprising  what  quantity  of  purgative 
or  emetic  medicine  will  sometimes  be  required  to  produce  an  effect, 
in  consequence  of  the  large  quantity  of  viscid  mucus  which  coats 
the  stomach  and  bowels.  It  is  this  method  of  treatment,  adopted 
with  energy,  which  is  found  to  be  the  most  efficacious  in  preventing 
the  appearance  of  those  symptoms  which  produce  the  condition 
denominated  scarlatina  maligna,  which  is  but  a  stage  of  collapse — 
an  effect  of  previous  excitement  of  very  uncertain  duration. 

Whenever  this  course  of  treatment  is  adopted,  great  alleviation 
often  follows  ;  but  when  it  has  been  neglected,  the  result  has  generally 
been  a  fatal  termination,  although  the  progress  of  the  disease,  in 
some  instances,  may  have  been  slow. 

The  head  is  sometimes  excessively  heated  in  this  stage  of  the  dis- 
ease, and  the  eyes  morbidly  sensible  to  the  light ;  under  this  condi- 
tion, blood  should  be  abstracted  locally  after  general  depletion,  cold 
applied  to  the  head,  and  purgatives  freely  given,  while  revulsions  are 
used  to  the  lower  extremities  ;  they  should  not,  however,  be  highly 
stimulating  while  the  excitement  is  high. 

Scarlatina  maligna  would  appear,  from  the  descriptions  usually 
given  of  it,  to  be  a  form  of  disease  always  distinct  from  all  others, — 
or  a  variety  which  can  at  once  be  recognised  as  possessing  some 
characters  peculiar  to  itself:  this  is  indeed  sometimes  the  case ;  but 
whoever  has  had  much  experience  in  our  late  epidemics,  must  have 
noticed  in  some  instances  cases  of  the  most  malignant  and  fatal 
character,  occurring  in  the  midst  of  every  shade  of  the  disease,  and 
perhaps  commencing  with  symptoms  so  mild  as  scarcely  to  excite 
alarm. 


APPENDIX.  561 

If  the  appearance  of  these  symptoms  be  sudden,  they  show  them- 
selves in  a  pecuUarly  variable  manner — the  skin  possesses  no  uni- 
formity of  heat — the  pulse  may  be  feeble  or  it  may  be  active — the 
eruption  may  appear,  recede,  and  reappear,  virithout  confining  itself 
to  any  particular  part  of  the  body  ;  but  the  interior  of  the  throat  will 
generally  be  found  ulcerated,  and  the  parts  surrounding  the  ulcer  of 
a  deep  modena  hue,  the  tongue  is  covered  with  a  dark  fur,  and  the 
breath  is  foetid — a  quantity  of  viscid  mucus  clogs  the  air-passages  ; — 
these,  together  with  symptoms  of  congestion  of  the  brain,  will  mark 
with  sufficient  distinctness  a  condition  which  may  almost  be  consid- 
ered as  necessarily  fatal. 

Nearly  the  same  symptoms  arise  after  the  disease  has  been  con- 
siderably prolonged ;  when  this  is  the  case,  the  throat  externally  is 
often  prodigiously  swelled.  There  is  in  this  stage  of  the  disease  a 
remarkable  pungency  of  the  skin,  and  a  dark  hue  of  the  eruption. 

When  these  symptoms  appear,  either  immediately  on  the  invasion 
of  the  disease,  or  as  a  sequela  of  the  preceding  inflammation,  it  may 
become  necessary  to  support  the  energy  of  the  circulation  by  the 
use  of  an  infusion  of  snake-root,  (Aristolochia  Serpentaria,)  or  per- 
haps on  some  occasions  by  a  little  wine  whey ;  but  bark,  wine,  cor- 
dials, and  other  stimulants,  recommended  by  some  practitioners, 
would  scarcely  have  been  considered  judicious  practice  during  our 
late  epidemics.  The  effect  of  these,  given  at  first  in  very  small 
quantities,  should  be  carefully  watched,  and  if  they  produce  a  dia- 
phoretic eflTect,  may  with  safety  be  continued  and  their  quantity  in- 
creased. 

In  order  to  remove  the  sloughs  and  to  produce  a  disposition  on 
the  part  of  the  ulcers  to  heal,  by  changing  the  character  of  the  in- 
flammation, various  stimulating  and  astringent  applications  have 
been  recommended,  such  as  diluted  muriatic  acid,  sulphuric  acid, 
tincture  of  bark,  solution  of  alum,  tincture  of  myrrh  or  capsicum,  or 
chloride  of  soda,  applied  to  the  affected  part,  by  means  of  a  swab, 
A  weak  solution  of  nitric  acid  has  been  found  very  useful.  Emetics 
are  here  highly  important,  and  indeed  necessary  to  cleanse  the  throat, 
and  to  remove  the  viscid  secretion  that  often  accumulates  in  the 
respiratory  passages.  The  bowels  ought  to  be  kept  soluble  by  mild 
laxatives  of  rhubarb  and  soda,  or  by  enemata.  Should  it  still  appear 
necessary  to  deplete,  diuretics,  as  judiciously  recommended  by  Dr. 
"Withers,  will  be  found  a  safe  method  of  effecting  this  object ;  and 
the  subcarbonate  or  acetate  of  potass  may  be  used. 

The  congestive  form  of  invasion  maybe  known  by  the  sudden 

71 


562  APPENDIX. 

seizure,  and  the  general  oppression  of  the  system ;  the  skin  is  ex 
cessively  pale,  and  I  have  heard  nurses  call  it  the  white  scarlet  fever. 
Where  no  reaction  occurs,  and  the  child  sinks  at  once,  it  is  not  until 
after  death  that  the  eruption  for  the  first  time  appears  ;  while  during 
life  the  entire  absence  of  this  distinctive  mark  of  the  disease  might 
easily  lead  to  an  error  in  the  diagnosis,  were  it  not  that  the  prevailing 
epidemic  gave  an  almost  certain  intimation  of  its  nature. 

When  it  appears  in  this  form,  all  the  means  in  our  power  must  be 
used  to  restore  an  equilibrium  to  the  circulation,  and  the  warm  bath, 
rendered  stimulating  by  the  addition  of  salt,  is  one  of  the  most  elfi- 
cent  means  for  this  purpose.  The  surface  of  the  body  may  be  rub- 
bed with  flannels  moistened  with  some  powerful  stimulant,  and  diluted 
aqua  ammonia?  is  probably  the  best  that  can  be  used  ;  and,  indeed, 
endermic  stimulation  in  cases  of  internal  congestion  is  far  more  effi- 
cacious than  the  internal  administration  of  stimulants  ;  for  although 
the  latter  may  produce  reaction,  yet  if  they  do  not  promptly  effect  it, 
they  doubtless  increase  the  existing  congestion  from  their  continually 
stimulating  influence.  When,  however,  it  is  deemed  advisable  to 
have  recourse  to  internal  stimulants,  wine  whey,  or  a  small  quantity 
of  tincture  of  camphor,  will  be  found  the  best.  Blisters  should  at 
the  same  time  be  applied  to  the  legs.  Bleeding  may  in  some  cases 
be  used,  but  with  great  caution  in  infants ;  for  it  must  be  borne  in 
mind  that  congestion  is  an  evidence  of  great  loss  of  vital  energy,  and 
that  the  abstraction  of  blood  might  be  quickly  fatal.  The  bowels 
ought  also  to  be  opened  with  a  full  dose  of  calomel,  promoting  its 
operation  by  enemata. 

Dr.  Charles  A.  Lee,  of  this  city,  has  obligingly  favored  me  at  my 
request  with  the  following  results  of  his  numerous  autopsic  exami- 
nations of  scarlet  fever : 

"  I  regard  the  local  inflammation  which  attends  scarlatina  as  a 
specific  aflfection,  identical  with  the  diphtheritis  of  Bretonneau  and 
other  French  writers,  and  characterized  chiefly  by  a  membranous 
exudation  on  the  surface  of  the  mucous  membrane  of  the  mouth  and 
fauces.  We  see  this  tendency,  also,  after  the  application  of  a  blister, 
and  indeed  wherever  the  cuticle  has  been  removed  by  any  cause 
whatever.  We  sometimes,  though  rarely,  find  it  extending  down 
the  trachea  and  bronchise,  giving  rise  to  all  the  symptoms  that  attend 
an  attack  of  croup. 

"It  is  however  important,  when  speaking  of  scarlatina,  to  keep  in 
mind  the  two  very  different  forms  which  it  assumes ;  namely,  the 
anfcinose  or  purely  inflammatory,  and  the  malignant  or  congestive 


APPENDIX.  563 

form,  in  which  we  have  a  frequent,  feeble  pulse,  cold  extremities, 
extreme  prostration,  and  great  determination  of  blood  to  the  head. 
In  the  latter,  patients  often  die  after  a  short  illness,  sometimes  before 
reaction  is  established,  and  in  such  cases  the  scalpel  reveals  nothing. 
The  citadel  of  life  has  been  invaded  by  an  invisible  foe,  and  its  forces 
have  succumbed,  leaving  behind  no  vestiges  of  the  attack. 

"In  treating  of  the  Pathology  of  Scarlet  Fever,  my  remarks  will 
naturally  fall  under  two  divisions,  namely,  1,  Lesions  of  the  Solids ; 
and  2,  Lesions  of  the  Fluids. 

"  I.  Lesions  of  the  Solids. — In  scarlatina,  there  is  hyperaemia  of 
the  mucous  membranes  generally,  and  of  the  mouth  and  fauces  in 
particular ;  which  constantly  tends  to  terminate,  either  by  a  membra- 
nous deposit  of  coagulable  lymph,  or  by  ulceration  ;  and  the  ulcera- 
tive process,  when  once  established  in  any  part,  is  very  apt  to  extend 
its  ravages  to  the  neighboring  parts  of  analogous  structure.  This 
inflammation,  we  have  reason  to  believe,  is  of  a  specific  character, 
depending,  probably,  on  the  peculiar  impression  made  on  the  nervous 
system  by  the  epidemic  influence.  At  a  very  early  period  in  the 
disease,  indeed,  before  any  constitutional  symptoms  appear,  we  shall 
perceive,  on  examining  the  fauces,  that  the  vessels  of  the  mucous 
membrane  are  highly  injected,  and  upon  the  surface  of  the  tonsils 
and  soft  palate,  gray  patches  of  lymph,  often  mistaken  for  ulcers, 
which  increase  in  extent  as  the  disease  progresses.  Preceding,  or 
accompanying  this  appearance,  we  sometimes  see  small  vesicles  of  a 
purple  or  whitish  color ;  and  these  are  sometimes  found  also  upon 
the  skin.  In  severe  cases  the  fauces  assume  a  deep  modena  red, 
or  purple  suffusion,  and  when  this  is  the  case,  ulceration  is  sure  to 
follow.  Flocculi  of  lymph  appear  scattered  over  the  surface  in 
irregular  patches,  resembling  in  appearance  the  purulent  secretion 
of  an  ulcer,  from  which  they  can  at  first  scarcely  be  distinguished. 
In  a  short  time,  however,  unless  removed  by  gargling,  or  some  other 
means,  these  patches  assume  a  dark  or  black  color,  attended  with  a 
peculiarly  oppressive  faetor.  On  removing  them,  the  surface  beneath 
appears  red,  spongy,  and  somewhat  swollen.  The  tonsils  are  more 
or  less  enlarged  from  the  commencement,  and  in  severe  cases  are 
almost  uniformly  the  seat  of  extensive  ulceration. 

^^  Autopsic  examination  by  no  means  reveals  the  same  appear- 
ances. In  many  cases  where  I  expected  to  find  extensive  local 
ravages,  there  were  scarcely  any  marks  of  disease  present ;  and  in 
others,  where  the  constitutional  symptoms  were  comparatively  light, 
I  have  found  the  most  frightful  vestiges  of  disease.     You  will  doubt- 


664  APPENDIX. 

less  recollect  the  case  of  the  child  in  Amos-street,  whose  dissection 
you  witnessed  a  short  time  since.  In  this  case  the  disease  assumed 
a  very  mild  form,  yielding  kindly  to  medicine.  In  a  few  days  the 
patient  was  apparently  well,  with  the  exception  of  a  slight  cough, 
and  the  physician  in  attendance  ceased  his  visits.  In  about  a  fortnight 
afterwards,  he  was  again  called  in,  and  found  her  laboring  under  an 
incessant  cough  of  a  croupy  character,  though  at  this  time  she  ,was 
playing  about  the  house.  In  two  or  three  days  afterwards,  she  died 
from  suffocation,  during  a  coughing  fit.  On  examination,  I  found 
a  great  portion  of  the  larynx  destroyed  by  ulceration,  and  the  fauces 
were  completely  honey-combed.  Numerous  perforations  existed  in 
the  tonsils,  palate,  &lc.,  of  various  sizes,  while  the  mucous  lining  of 
the  trachea  was  either  softened,  or  abraded,  through  its  whole  extent. 
There  was  a  vast  collection  of  frothy,  muco-purulent  matter  collected 
in  the  larynx  and  trachea,  which  doubtless  was  the  cause  of  the  suf- 
focation.    The  other  organs  were  healthy. 

"  In  another  case,  which  happened  not  long  after,  you  also  was 
present  at  the  examination,  and  can  bear  testimony  to  the  great  dif- 
ference in  the  appearances,  on  dissection,  from  those  above  given. 
The  patient  was  a  boy,  five  years  of  age :  at  an  early  period  there 
was  considerable  redness  about  the  fauces,  and  the  tonsils  were 
somewhat  swollen.  The  breath  was  hot  and  offensive,  and  the  pulse 
ranged  from  120  to  140.  There  was  extreme  restlessness  and  jacti- 
tation throughout  the  whole  course  of  the  disease,  with  frequent 
moaning  and  screaming,  a  wild  expression  of  the  eyes,  irregular 
and  often  labored  respiration,  temperature  of  the  body  very  unequal, 
head  generally  hot,  and  extremities  cold.  As  the  disease  progressed, 
his  mouth  and  lips  became  encrusted  with  a  dark  brown  sordes ;  the 
tongue  was  swollen,  fiery  red,  and  cracked;  the  throat  became  filled 
with  a  thick,  glutinous,  tenacious  mucus ;  the  stomach  was  ex- 
tremely irritable,  and  the  epigastrium  tender  on  pressure.  There 
was  more  or  less  delirivmi  throughout  the  whole  sickness.  He  sunk 
into  a  stupor,  and  died  on  the  sixth  day  from  the  attack. 

^'Autopsy  eight  hours  after  death. — Body  emaciated;  a  few  black 
spots  on  the  posterior  part  of  the  body  ;  a  yellowish  mucus  dis- 
charging from  the  mouth  and  nose,  in  considerable  quantity.  The 
lungs  were  found  healthy,  and  remarkably  free  from  blood  ;  no  marks 
of  inflammation  about  them  ;  and  on  cutting  into  them,  we  found 
but  very  slight  effusion  into  the  air-cells.  The  mucous  surface  of 
the  trachea  and  bronchia  was  covered  with  a  white  mucus,  wliich, 
on  being  removed,  the  membrane  presented  a  healthy  appearance. 


APPENDIX.  5(35 

The  liver  was  healthy ;  the  gall-bladder  full  of  bile  ;  the  heart  natural ; 
and  the  pericardium  contained  the  usual  quantity  of  serum.  There 
was  no  ulceration  about  the  fauces,  tonsils,  or  palate,  and  the  whole 
lining  membrane  of  the  mouth  was  perfectly  healthy.  It  is  proper, 
perhaps,  to  remark,  that  this  patient  had  been  very  freely  bled  and 
leeched. 

"  We  however  generally  find  in  this  disease  ulceration  about  the 
glottis  and  tonsils,  of  greater  or  less  extent,  though  the  hyperaemiae 
of  the  mucous  membrane,  so  constant  during  life,  is  very  apt  to  dis- 
appear after  death.  The  same  is  also  true  of  the  vascularity  of  the 
mucous  coat  of  the  stomach,  and  small  intestines.  The  air-passages 
very  often  present  pathological  alterations.  We  sometimes  see 
merely  a  vascularity  of  the  lining  membrane,  at  other  times  a  thicken- 
ing, and  occasionally  ulceration.  It  is  not  uncommon  to  find  the 
trachea  and  bronchae  filled  with  a  thick,  tenacious  matter,  of  a  muco- 
purulent character.  In  a  few  cases,  I  have  discovered  marks  of 
inflammation  about  the  lungs  and  pleura;  but  this  is  by  no  means  of 
frequent  occurrence,  and,  when  present,  are  to  be  viewed  as  an  acci- 
dental complication.  Where  leeching  and  venesection  have  not  been 
practised,  the  lungs  will  frequently  be  seen  gorged  with  blood.  In 
those  cases,  attended  with  an  acrid  sanious  discharge  from  the  nos- 
trils, and  where  there  is  a  tendency  to  the  formation  of  a  glutinous, 
brown  sordes  on  the  mouth  and  teeth,  I  have  invariably  found  more 
or  less  extensive  marks  of  disease  about  the  brain  ;  and  the  former 
symptom,  particularly,  I  have  been  led  to  consider  as  a  highly  dan- 
gerous one,  from  its  indicating,  with  great  certainty,  such  a  compli- 
cation. In  these  cases,  the  vessels  of  the  brain  will  be  found  injected, 
particularly  of  the  membranes,  and  there  will  be  found  an  efiusion 
of  turbid  lymph  between  the  arachnoid  and  pia  mater,  and  also  more 
or  less  serum  in  the  ventricles.  In  the  highly  congestive  cases,  where 
death  has  speedily  resulted,  wt-  find  few  marks  of  disease  about  the 
throat ;  but  the  bloodvessels  of  the  larger  organs,  particularly  the 
brain,  lungs,  and  liver,  will  be  distended  with  dark-colored  blood. 
Dr.  Armstrong,  in  his  work  on  scarlet  fever,  remarks,  'From  the 
examination  of  several  bodies  after  death,  I  am  warranted  in  afiirm- 
ing  that  the  brain,  the  liver,  the  stomach,  the  intestines,  and  the 
lungs  are  the  parts  most  often  inflamed,  and  that  the  inflammation 
in  these  parts  is  generally  the  cause  of  death,  together  with  the 
affection  of  the  throat.'  But  I  have  examined  many  cases  where 
death  could  not  be  said  to  have  resulted  from  either  of  these  causes, 
for  in  two  of  them  the  patient  died  within  nine  hours  of  the  attack, 


566 


APPENDIX. 


and  nothing  but  congestion  of  the  larger  organs  could  be  discovered. 
In  some  of  these  cases  of  congestive  scarlet  fever,  the  symptoms 
bear  a  striking  resemblance  to  those  produced  by  the  narcotic  poi- 
sons ;  there  is  the  same  abolition  of  sense,  and  the  power  of  motion, 
frequently  combined  with  convulsions;  a  contracted  pupil;  and 
labored,  or  even  stertorous  respiration.  The  appearances  on  dis- 
section are  also  the  same.  Hence,  I  have  been  led  to  conclude  that 
the  contagious  principle  occasioning  the  disease  is  a  specific  virus, 
of  a  gaseous  nature,  which,  being  introduced  into  the  system  through 
the  medium  of  the  bloodvessels  of  the  lungs,  acts,  as  narcotics  also 
do,  either  upon  the  brain,  or  spinal  marrow,  or  both.  These  notions 
are  in  a  great  degree  assumptions,  it  is  true;  but  if  any  one  can 
invent  a  more  satisfactory  hypothesis,  I  should  be  very  glad  to 
adopt  it. 

''''Lesions  of  the  Fluids. — With  respect  to  lesions  of  the  fluids  in 
scarlet  fever,  so  little  progress  has  hitherto  been  made  in  animal 
chemistry,  that  but  Httle  can  be  said  with  any  degree  of  certainty. 
You  are  doubtless  acquainted  with  Naumann's*  hypothesis,  which 
supposes  that  some  change  is  wrought  by  the  epidemic  influence 
upon  the  properties  of  the  blood,  rendering  its  albuminous  constitu- 
ents incapable  of  being  held  in  solution  by  the  serum,  in  consequence 
of  which,  the  former  exude  upon  the  surface  of  the  mucous  membranes, 
in  form  of  a  deposit,  as  we  see  about  the  throat  and  fauces  in  this 
disease.  Again,  it  is  the  opinion  of  Donne,  that  in  scarlet  fever  the 
secretions  become  highly  acid  ;  and,  as  Geddings  remarks,  if  we 
admit  as  valid  the  opinion  of  Raspail,  that  fibrine  is  merely  albumen 
coagulated  by  an  acid,  we  thus  acquire  a  reason  why  the  serum  loses 
its  power  of  holding  the  albumen  in  a  state  of  solution.  But  how- 
ever this  may  be,  there  is  most  obviously  a  deterioration  of  the 
secretory  and  nutritive  functions,  owing,  doubtless,  to  an  impairment 
of  the  nervous  energy.  There  is,  consequently,  a  change  in  the 
constituents  of  the  blood,  either  as  to  quantity  or  quality,  or  both, 
and  a  derangement  of  the  vital  forces,  which  renders  them  incapable 
of  speedily  repairing  such  lesions  as  are  the  result  of  the  inflamma- 
tory engorgement,  or  even  of  throwing  ofl?*  the  disease,  when  violent 
in  its  attack.  Owing  to  this  same  impairment  of  nervous  power, 
there  is  a  strong  tendency  to  dissolution,  both  in  the  solids  and  fluids, 
manifested  both  by  the  rapid  changes  which  occur  after  death,  as 
well  as  during  life. 

"  The  above  remarks  apply  to  scarlet  fever  at  every  age." 

*  Handbuch  der  Medecinischen  Klinik. 


APPENDIX.  667 

On  the  subject  of  dropsical  affections  occurring  after  scarlatina, 
Dr.  Stark  of  Edinburgh  makes  some  very  judicious  observations. 
(See  Amer.  Jour.  Med.  Scien.,  vol.  xix.,  p.  507.) 

He  remarks  that  they  are  more  frequent  during  the  months  of  Oc- 
tober, November,  December,  and  January,  than  afterwards ;  gener- 
ally a  fortnight  after  the  disappearance  of  the  eruption  ;  and  some- 
times very  suddenly,  without  any  previous  complaint.  In  every 
instance  where  the  urine  was  examined,  it  was  found  coagulable  by 
heat. 

He  considers  cold  applied  to  the  surface  of  the  body  in  some  way 
or  other  as  the  immediate  cause  of  these  dropsical  symptoms. 
There  is  an  increased  vascular  action  in  the  cutaneous  system  to 
supply  the  loss  of  the  cuticle  which  occurs  in  this  disease;  but,  from 
the  want  of  tone  in  the  larger  vessels,  the  surface  of  the  body  is  easily 
chilled,  and  the  blood  circulating  there  is  thrown  on  the  internal 
organs  ;  and  the  kidneys  are  the  first  to  suffer ;  which,  from  their 
weakened  condition,  undergo  a  disordered  action  and  a  suspension 
of  secretion.  This  is  proved  by  "  several  recorded  dissections  of 
persons  who  have  died  from  this  disease." 

"  In  all  cases,"  says  he,  "  excepting  the  very  mildest,  I  bled  to  a 
greater  or  less  extent,  in  proportion  to  the  severity  of  the  symptoms, 
and  the  relief  experienced  from  it.  Wherever  it  was  practicable,  or 
the  parents  would  allow  it,  bloodletting  from  the  vein  in  the  arm 
was  preferred,  because  the  symptoms  were  much  sooner  relieved  by 
such  a  practice,  and  more  effectually  than  when  leeches  were  applied 
to  the  loins  or  other  parts  of  the  body.  When,  however,  this  was 
impracticable,  or  where  the  child  was  under  two  years  of  age,  leeches 
were  used,  but  always  in  such  numbers  as  to  cut  short  the  disease  as 
soon  as  possible,  and  not  trust  to  the  removal  of  the  requisite  quan- 
tity of  blood  by  subsequent  fomentation  ;  though  these  were  also 
occasionally  employed.  In  all  the  severe  cases,  the  safest  and  most 
certain  mode  of  relieving  all  the  urgent  symptoms,  was  to  carry  the 
bloodletting  to  such  an  extent  as  to  produce  a  marked  action  on  the 
pulse."  Only  one  case  out  of  fifteen  cases  of  dropsical  sequelae  died, 
and  in  this  one  the  parents  would  not  allow  of  bleeding  either  by  the 
lancet  or  by  leeches.  In  addition  to  this,  the  doctor  prescribes 
liquor  ammonicB  acetatis  where  the  urine  is  entirely  suppressed.  In 
mild  cases,  purgatives,  antimonials,  liquor  ammonics  acetatis,  and 
warm  bath  removed  all  the  symptoms. 

The  blood  drawn  in  these  cases  usually  presented  a  buffed  appear- 
ance, and  was  occasionally  cupped. 


568  APPENDIX. 

In  support  of  these  views,  Dr.  R.  K.  Hoffman  states,  that  in  the 
only  case  that  occurred  to  him  of  this  dropsical  affection  that  was 
fatal,  jEibrin  was  found  covering  the  surface  of  the  liver  and  pleura, 
which  had  not  yet  formed  adhesions,  but  could  be  peeled  off  with  the 
greatest  ease. 

ACARUS    SCABIEI,  OR    ITCH    INSECT. 
Note  to  page  116. 

No  doubt  now  exists  of  the  acarus  being  an  attendant  on  the  itch, 
from  experiments  a  few  years  since  at  the  Hdpital  St.-Louis,  in 
Paris. 

The  size  of  the  insect  is  about  that  of  the  mark  which  would  be 
left  by  the  pricking  of  the  finest  needle. 

"  The  acarus  scabei,  seen  through  the  microscope,  presents  the 
form  of  a  tortoise,  a  shining  surface,  more  transparent  in  the  centre 
than  at  the  circumference,  of  a  white  color.  Its  other  shades  would 
appear  to  be  the  result  of  the  division  of  luminous  rays  passing 
through  the  lens.  The  head,  which  may  be  considered  as  a  perfect 
retracting  sucker,  is  provided  at  each  side  with  two  articulated  feet, 
terminating  at  the  tarsus,  in  a  funnel-shaped  prolongation.  The  in- 
sect is  armed  with  four  additional  feet,  longer  than  the  former,  but 
without  the  funnel-shaped  appendage ;  this  articulation  is  not  at  the 
sides  like  those  of  the  horse  acarus,  but  underneath  the  belly  ;  on 
the  back  is  perceived  a  number  of  eccentric  lines  at  short  intervals, 
and  having  the  appearance  of  joints ;  the  belly  presents  several 
dark-colored  spots  ;  the  body  and  legs  seemed  furnished  with  a 
quantity  of  hair  of  unequal  length."  (Raspail,  as  quoted  by  the 
Lancet,  October,  1834.) 

VACCINIA. 
Note  to  page  121. 

The  source  whence  the  information  contained  in  the  text  relative 
to  the  proportionate  mortality  of  smallpox  in  this  country  is  taken, 
is  probably  the  able  report  of  the  Committee  of  the  Philadelphia 
Medical  Society,  appointed  to  collect  facts  in  relation  to  the  small- 
pox, which  prevailed  in  that  city  in  the  year  1827. 

There  appear  to  have  been  about  two  hundred  and  thirty-five  cases 
of  smallpox  reported  to  the  board  of  health,  and  one  hundred  deaths 
from  the  disease  in  the  same  year :  the  mortality  is  therefore  not  so 
great  as  stated  by  the  author. 

From  this  report,  the  result  of  a  mass  of  evidence  accumulated 


APPENDIX.  569 

from  a  number  of  highly  respectable  sources,  the  powerfully  pro- 
tecting influence  of  vaccination  is  placed  beyond  a  doubt ;  for  it  ap- 
pears that  but  one  death  from  smallpox  after  vaccination  occurred 
in  Philadelphia  in  1827,  among  eighty  thousand  vaccinated  persons, 
during  the  prevalence  of  a  malignant  and  mortal  smallpox,  while 
several  persons  lost  their  lives  from  it  after  they  had  already  gone 
through  the  disease.     (See  American  Jour.  Med.  Sciences,  1828.) 

APTHTH^. 

Note  to  page  179- 

Practical  writers,  (Evanson  and  Maunsell,  and  others,)  observe 
that  there  is  a  remarkable  absence  of  all  constitutional  symptoms  in 
young  infants  in  this  affection,  even  when  there  exists  much  gastro- 
intestinal inflammation,  but  about  the  time  of  dentition  the  febrile 
action  becomes  very  evident.  In  severe  affections,  the  bowels  are 
greatly  disordered,  and  the  stools  are  thin  and  offensive,  and  without 
any  bile.  In  the  treatment  of  this  disease,  the  first  and  most  obvious 
indication  is  to  attend  to  the  diet  and  regimen,  as  it  occurs  mostly  in 
those  that  are  badly  nourished,  and  that  are  exposed  to  the  influence 
of  impure  air.  When  the  mucous  membrane  of  the  digestive  pas- 
sages does  not  exhibit  any  evidences  of  a  phlogosed  condition,  mild 
aperients,  as  magnesia  and  rhubarb,  or  castor  oil,  have  sometimes  re- 
moved an  attack  of  aphthae.  Emetics  have  been  highly  recommended 
by  the  writers  alluded  to  above,  to  free  the  stomach  from  the  morbid 
matters  which  may  have  been  swallowed,  and  which  become  the 
source  of  irritation  ;  they  should  of  course  be  given  with  the  caution 
above  mentioned.  Where  there  is  evidence  of  inflammatory  action 
in  the  bowels,  and  if  the  discharges  are  streaked  with  blood,  the  use 
of  purgatives  should  be  avoided  ;  a  flaxseed  poultice  should  then 
be  applied  to  the  abdomen.  Anodynes  are  often  very  serviceable 
when  there  is  much  restlessness,  and  Dover's  powder  will  be  the  most 
efficacious,  combined  with  prepared  chalk,  when  there  is  much  diar- 
rhoea present.  Drs.  Evanson  and  Maunsell  advise  ammonia  as  the 
best  stimulant,  where  there  exists  great  prostration ;  being  careful  to 
avoid  the  error  of  mistaking  the  absence  of  fever  for  the  sinking  of 
gangrene.  Sulphate  and  tannate  of  quinine  have  been  recommended 
when  tonics  are  indicated,  and  iodine  has  been  used  with  evident 
advantage  in  some  protracted  cases. 

As  local  applications.  Dr.  Dewees  uses  Armenian  bole  mixed  with 
sugar,  both  finely  powdered ;  or  a  decoction  of  half  an  ounce  of  pow- 

72 


570  ■   •      APPENHIX. 

dered  bark,  boiled  for  half  an  hour  in  h^f  a  pint  of  water,  a  tea- 
spoonful  of  "vVhich  is  to  be  put  in  the  child's  mouth  every  hour  or 
two.  Borax  is  an  excellent  and  popular  remedy ;  it  may  be  applied 
eithisr  in  the  form  of  powder  mixed  with  sugar,  or  in  solution,  in  the 
proportion  of  a  drachm  in  two  ounces  of  water.  In  very  obstinate 
cases,  sulphate  of  copper,  or  nitrate  of  silver  have  been  used,  and 
have  quickly  changed  the  character  of  the  ulcers.   . 

Gangrene  of  the  mouth^ 

Note  to  page  192. 

M.  Marjolin,  in  the  article  '*  Gangrene  de  la  bouche,"  in  the  Dic- 
tionnaire  de  Medecine,  recommends  muriatic  acid  and  honey,  muriate 
of  soda,  and  caustic  potash,  which  he  says  have  been  employed  with 
success.  MM.  Jadelot  and  Guersent  have  also  successfully  used  the 
actual  cautery.  Dr.  Burns  advises  chloride  of  lime,  nitrate  of  silver, 
carrot  or  yeast  poultice  ;  nitric  acid  as  a  local  application  has  like- 
wise been  used  with  advantage. 

The  application,  however,  which  has  succeeded  beyond  all  com- 
parison, is  the  sulphate  of  copper,  and  the  rapidity  of  the  cure  under 
its  use  is  in  some  cases  surprising.  It  is  far  preferable  to  the  use 
of  actual  cautery  ;  it  can  be  applied  with  the  greatest  facility  to  ev- 
ery portion  of  the  diseased  surface ;  care  and  attention  are  requisite 
to  see  that  every  part  of  the  diseased  part  is  brought  under  the  influ- 
ence of  the  application,  as.  a  failure  might  otherwise  ensue.  Simple 
ulcerations  and  small  gangrenes  quickly  yield  to  the  use  of  this  means, 
and  an  amendment  is  evident  from  the  first  application.  The  solu- 
tion should  be  made  strong,  as  in  the  formula  at  the  fend  of  the  ap- 
pendix. (See  Dr.  Coates's  article  in  N.  A.  Med.  and  Surg.  Journal, 
1826.) 

EDENTULA. 

Note  to  page  203. 

M.  Baumes  mentions ,  the  case  of  a  soldier  who  never  had  any 
teeth  from  his  birth.  .  Dr.  Fitch,  in  his  system  of  dental  surgery, 
gives  an  instanc.e  of  a  gentleman  in  whom  the  bicuspid  teeth  of  the 
lower  jaw  never  appeared,  and  also  of  a  young  lady  who  never  had 
the  lateral  incisores  of  the  upper  jaw ;  and,  what  is  more  surprising, 
that  of  a  family  of  whom  several  individuals  never  had  any  teeth. 
This  affection  was  in  the  last  mentioned  instance  hereditary,  and  had 
been  remarked  for  several  generations. 


APPENDIX. .  571 


TEETHING.  . 
Note  to  page  210. 

The  disturbances  produced  by  dentition  are  in  a  healthy  child  often 
so  slight  as  to  require  little  or  no  attention.  The  gums  will,  howeyer, 
sometimes  become  greatly  swelled,  the  mouth  hot,  and  the  secretion 
of  saliva  suspended;  under  these  circumstances,  there  is  nothing 
which  will  give  more  speedy  relief  to  the  inflamed  and  painful  gums 
than  a  free  incision  through  them  to  the  teeth.  If  there  exist  any 
disease,  although  the  teeth  may  not  be  the  cause  of  the  existing  dis- 
turbance in  the  system,  yet  the  pressure  they  make  on  the-  nerves 
in  the  socket,  and  the  tension  of  the  membrane  covering  the  crown 
of  the  teeth,  are  sources  of  great  irritation  in  the  delicate  and  sus-. 
ceptible  system  of  infants ;  and  may  thus  aggravate  the  various  dis- 
eases ^vith  which  they  may  be  affected  ;  for  il  can  hardly  be  doubted 
that  many  diseases  which  at  another  period  of  life  would  have  ter- 
minated favorably,  have  frequently  been  fatal  in  the  irritable  state 
attending  the  period  of  dentition :  and  that  such  is  the  case,  appears 
evident  from  the  great  mortality  among  children  while  teething.  On 
this  account,  the  gums  ought  freely  to  be  divided. in  diseases  of  in- 
fancy, should  there  even  exist  no  actual  swelling,  but  simply  an  ex- 
pansion of  the  gum  over  the  teeth. 

The  objections  urged  against  this  operation,.except  when  the  gums 
are  actually  inflamed,  are — that  the  physician  may  endanger  his  rep- 
utation should  the  tooth  not  appear — that  the  cicatrix  left  on  the  heal- 
ing of  the  gum  is  much  harder  than  the  surrounding  gum,  and  that  the 
incision  may  degenerate  into  an  ulcer.  Now  if  the  tooth  be  suspected 
to  be  a  source  of  aggravation  to  the  existing  disease,  and  it  be  deemed 
necessary  by  the  physician  to  cut  down  to  it,  even  though  it  be  still 
deeply  imbedded,  in  order  to  liberate.it  fromits  investing  membrane, 
the  nature  and  object  of  the  operation  can  easily  be  explained  to  the 
parents.  With  regard  to  the  formation  of  a  cicatrix  on  the  healing 
of  the  incision,  this  would  rather  promote  than  retard  the  passage  of 
the  tooth,  for  it  is  well  known  that  a  cicatrix  is  much  sooner  removed 
by  absorption  than  the  surrounding  parts.  If  an  ulcer  appear,  it 
will  be  speedily  removed  by  a  wash  made  with  the  decoction  of  Cop- 
tis  trifoliata,  alum,  or,  when  severe,  by  the  application  of  sulphate 
of  copper.  In  cases  of  any  form  of  stomatitis  from  teething,  blisters 
behind  the  ears  are  of  great  service.  '• 

The  use  of  hard  smooth  substances  for  the- purpose  of  pressing  on 
the  gums,  has  been  objected  to  by  the  author,  but  it  may  safely  be 


572 


APPENDIX. 


left  to  the  instinctive  propensity  of  the  child ;  for  when  the  process 
of  teething  is  unattended  with  any  inflammation  of  the  gums,  the 
pressure  produces  no  pain,  and  tends  much  to  facilitate  the  absorp- 
tion of  the  gums  ;  but  their  use  is  obviously  injurious  in  an  inflamed 
state  of  these  parts,  and  the  child  will,  under  such  circumstances,  in- 
stinctively avoid  them.  They  can  hardly  be  classed  with  amulets  or 
charms,  and  placed  on  a  level  with  the  brains  of  a  sucking  pig,  milk 
of  a  bitch,  or  blood  of  a  cock's  comb,  which,  on  being  applied  with 
the  fingers,  it  was  formerly  said,  caused  the  production  of  teeth 
without  difliculty.  The  use  of  these  hard  substances  appears  to 
have  been  common  to  all  ages  and  among  all  descriptions  of  people; 
some  of  the  aborigines  of  our  country  used  smooth  stones  for  the 
purpose  of  relieving  children  while  teething.  (See  Major  Long's 
3d  Expedition,  vol.  i.,  p.  312.) 

BLOODLETTING. 

Note  to  page  269. 

A  difference  of  opinion  has  prevailed  among  writers  upon  the  sub- 
ject of  general  bloodletting  in  infants.  Sydenham,  Cuming,  and 
others  have  strongly  advocated  its  use;  while  others,  principally 
German  and  French  physicians,  Laennec,  Henke,  Vogel,  etc.,  prefer 
local  bleeding  by  cups  or  leeches  in  inflammatory  diseases  of  young 
children,  and  Henke  even  limits  the  number  of  leeches  to  two  for 
children  under  a  year ;  others  have  directed  six  as  the  full  number  to 
be  applied  to  a  child  that  has  completed  a  year ;  indeed,  of  late  the 
method  of  depleting  by  leeches  has  become  so  general  in  treating 
these  diseases,  as  almost  to  have  taken  the  place  of  the  lancet.  This 
extensive  substitution  of  leeches  for  the  lancet  cannot  be  regarded 
as  an  improvement  in  practice.  A  brief  examination  of  the  usual 
condition  of  young  children  may  perhaps  exhibit  this  question  in  its 
proper  light. 

Infants  are  born  with  the  organs  ofdigestion  and  nutrition  in  a  state 
of  perfection,  so  far  at  least  as  the  former  are  adapted  to  the  food 
naturally  provided  for  them.  The  desire  for  food  and  the  act  of  def- 
ecation are  frequent,  and  are  evidences  of  the  rapidity  of  the  digestive 
process.  This  promptness  of  digestion  is  indeed  necessary  where 
there  is  so  great  a  demand  for  materials  for  the  growth  of  the  body, 
nutrition  or  the  process  of  composition  being  a  function  also  per- 
formed with  great  activity ;  and  if  there  be  any  period  of  life  in 
which  the  growth  of  all  parts  predominates,  it  is  in  infancy  ;  and  it 


APPENDIX.  573 

has  been  remarked  that  the  growth  of  an  infant  is  greater  during  the 
first  year  than  during  the  third,  fourth,  or  fifth. 

The  effect  of  this  rapid  assimilation  is  the  formation  of  abundance 
of  blood ;  vessels  of  the  sanguineous  and  capillary  systems  abound, 
and  blood  exists  in  large  quantities  in  every  tissue ;  while  the  high 
color  of  the  skin,  and  the  round,  plump  form,  prove  the  prevalence 
of  fluids  over  the  solids,  and  that  plethora  is  generally  the  prevailing 
condition  of  infants.  During  this  rapid  increase  the  parenchyma- 
tous circulation  is  in  a  high  state  of  activity ;  and  if  the  formation  of 
parts  proceeds  without  interruption  or  any  local  stimulation,  by  which 
the  quantity  of  blood  may  be  increased  beyond  the  natural  requisition 
of  the  part,  the  healthy  deposition  and  consequent  growth  continue. 
A  slight  excess  of  this  natural  action,  however,  produces  an  abnor- 
mal state,  and  the  necessary  increase  of  the  phenomena  which  ac- 
company the  action  of  the  bloodvessels,  such  as  exaltation  of  sensi- 
bility, evolution  of  heat,  &.C.,  are  the  evidences  that  this  augmented 
action  has  taken  place,  a  condition  of  parts  possessing  the  characters 
which  distinguish  inflammatory  action  ;  thus  showing  that  the  latter 
differs  from  the  normal  process  of  increase  only  in  degree,  and  that 
there  is  but  a  step  between  healthy  interstitial  circulation  attendant 
on  the  growth  of  a  part  and  the  diseased  action  of  the  vessels  con- 
stituting inflammation. 

Now  since  activity  in  the  minute  vessels  of  the  growing  infant  is 
so  evident,  and  since  this  activity  may  easily  pass  beyond  the  healthy 
action,  upon  the  application  of  a  stimulating  agent,  we  might  expect 
to  find  infants  greatly  liable  to  inflammatory  or  congestive  diseases, 
and  for  the  same  reason  their  diseases  would  be  more  simple,  more 
free  from  those  complications  which  not  unfrequently  attend  them  in 
advanced  life,  and  which  on  this  account  often  require  at  the  latter 
period  the  nicest  judgment  in  their  treatment.  This  liability  to  in- 
flammation and  congestion  is  fully  proved  by  daily  experience ;  and 
the  freedom  from  complication,  it  is  well  known,  exists  in  a  remark- 
able degree  in  infants,  in  consequence  of  which  bloodletting,  when 
properly  employed,  is  attended  with  less  hazard  than  in  adults,  and 
their  inflammatory  diseases  are  much  sooner  relieved  by  early 
bleeding. 

As  infants  abound  in  blood,  and  as  nutrition  proceeds  with  rapid- 
ity in  their  organs,  any  interruption  to  the  normal  action  of  the  ves- 
sels in  the  formation  of  parts  will  give  rise  to  violent  congestions  or 
inflammation,  demanding  an  early  interference  for  their  removal. 
The  progress  of  acute  inflammatory  diseases  is  often  very  rapid,  so 


674 


APPENDIX. 


rapid  indeed  that  for  the  most  part  there  is  but  little  time  left  for  the 
employment  of  appropriate  means  for  their  removal;  sudden  effu- 
sions of  serum  or  lymph  often  occurring  in  .a  surprisingly  short 
space  of  time  after  they  are  attacked.  On  this  account  it  is  that  their 
active  inflammatory  affections  require  early  and  energetic  attention, 
and  it  is  certainly  aji  error  to  suppose  that  gen-eral  bloodletting 
ought  not  to  be  used  for  that  purpose. 

If  the  positions  here  taken  be  correct,  the  age  of  the  patient, 
which  has  been  advanced  as  an  objection  to  the  use  of  the  remedy 
now  under  consideration,  far  from  being  a  sufficient  reason  for  aban- 
doning it,  is,  On  the  contrary,  a  reason  why  it  should  .be  early  adopt- 
ed ;  and  venesection  cannot  be  any  more  "  safe  when  the  child  has 
attained  the  age  of  one  year,"  than  before  that  period  ;  the  nature 
of  the  affection  and  the  constitutional  vigor  of  the  individual  must 
be  the  basis  on  which  our  judgment  as  to  the  necessity  of  its  em- 
ployment must  be  founded :  and  indeed  so  necessary  is  this  opera- 
tion when  young  children  are  attacked  with  congestion  or  acute 
inflammation  in  an  organ  essential  to  life,  and  it  is  to  such  cases  we 
.  of  course  limit  venesection,  that  it  would  be  difficult  to  find  a  remedy 
if  general  bloodletting  were  rejected. 

No  better  directions  can  be  given  for  the  employment  of  blood- 
letting than  those  of  Celsus,  eighteen  hundred  years  since.  Speak- 
ing of  bloodletting,  "  incisa  vena,"  the  distinguished  compiler  of 
Roman  medicine  remarks  :  "  Interest  enim,  non  qu«  aetas  sit,  sed 
quae  vires  sint."  (Celsus,  lib.  ii.  ^  x.)  He  then  considers  the  niature 
of  the  disease,  and  if  there  exist  a  deficiency  of  fluids'  the  remedy 
is  prejudicial;  if  on  the  other  hand  there  is  a  redundancy  of  humors, 
no  remedy  is  so  successful.  "  Ergo,  vehemens  febris  ubi  rubet  cor- 
pus, plaenequae  venae  tumcnt  sanguinis  detractionem  requirit."  (Lo- 
co citato.)  There  can  be  no  better  rule  given  for  bloodletting,  in 
any  disease  or  at  any  ag«  ;  subject  always  to  the  exceptions  which 
may  occur  in  individual  cases,  in  epidemics  of  a  peculiar  character, 
or  the  condition  of  life  of  any  class  of  people,  by  which  a  deficiency 
of  constitutional  energy  may  exist,  bearing  a  resemblance  to  a  simi- 
lar condition  in  adults. 

It  has  been  remarked  that  bleeding  is  attended  with  great  hazard 
in  the  state  of  exalted  susceptibility  of  the  nervous  system  of  infants  ; 
and  the  danger  of  convulsions,  to  which  they  are  liable,  has  been 
used  as  an  argument  for  its  rejection  altogether;  the  danger  has  been 
greatly  exaggerated,  and  it  is  probable,  when  these  symptoms  have  oc- 
curred, that  bleeding  has  been  carried  to  excess,  or  that  it  was  not  re 


APPENDIX.  575 

quired  ;  but  alarming  prostration  from  loss  of  blood  will  arise  from 
capillary  bleeding  as  well  as  from  that  by  the  lancet ;  indeed,  the  only 
instances  in  which  such  symptoms  have  occurred  to  the  writer  have 
been  where  leeches  were  employed ;:  it  is  exceedingly  difficult  to 
ascertain  the  quantity  of  blood  lost  in  this  manner,  and  a  larger 
quantity  may  be  taken  than  the  case  requires ;  for  it  ought  to  be 
borne  in  mind  that  the  loss  of  blood,  like  the  dose  of  a  medicine, 
has  its  limit. 

The  effects  and  risk  of  all  measures  employed  in  the  treatment  of 
diseases_  ought  in  every  instance  to  be  estimated  by  the  practitioner, 
and  where  the  use  of  the  lancet  is  deemed  necessary,  the  probable 
bad 'effects  on  the  system  should  also- be  taken  into  account,  and 
means  used  to  anticipate  or  correct  them,,  by  proportioning  the 
quantity  to  the  exigency  of  the  case,  or  by  using  appropriate  meas- 
ures for  the  relief  of  these  symptoms  when  they  arise.  It  is  seldom 
we  prescribe  for  any  morbid  affection  without  producing  temporarily 
an  artificial  diseased  action  of  another  form,  which  if  .it  be  violent 
must  of  itself  become  of  serious  import ;  hence  the  daily  practice  pf 
combining  in  the  most  common  prescriptions  articles  intended  to  in- 
fluence, control,  or  perhaps  in  some  degree  to  counteract  the  effects 
of  a  simple'  medicine  possessing  powerful  properties.  Ought  we 
not,  also,  in  the  case  of  artificial  hemorrhage,  which  it  has  been 
deemed  necessary  to  induce,  be  ready  to  anticipate  or  remove  any 
evil  effects  which  may  arise,  instead  of  rejecting  it  because  it  may 
be  followed  by  alarming  symptoms?  Nervous  symptoms,  or.  ex- 
haustion from  loss  of  blood,  can  only  arise  from  bloodletting  being 
carried  beyond  its  proper  extent.  The  means  necessary  to  prevent 
these  effects  are  to  bleed  early  in  the  disease,  while  the  heart  still 
possesses  power  to  carry  on  the  circulation  with  vigor,  to  proportion 
the  quantity  of  blood  drawn  to  the  violence  of  the  symptoms  and  to 
the  age  and  constitution  of  the  child,  carefully  watching  the  first  evi- 
dence of  its  effects,  when  the  flow  of  blood  should  be  arrested  ;  and 
when  these  symptoms  appear,  or  when  there  is  reason  to  apprehend 
their  occurrence,  to  quiet  the  action  of  the  nervous  system  by  the 
administration  of  Dover's  powder  or  a  little  laudanum. 

.  It  is  at  the  commencement  of  inflammatory  diseases  that  the  gopd 
effects  of  bloodletting  are  apparent,  and  the  earlier  it  is  performed 
the  more  decided  will  be  the  benefit ;  and  the  relief,  especially  in 
pneumonia,  is  often  immediate  and  lasting;  the  practice  just  stated 
will  be  found  a  powerful  adjunct  to  the  bleeding,  calming  the  nervous 
irritation,  and  producing  a  determination  to  the  surface  ;  a  quiet  re- 


576  APPENDIX. 

pose  follows,  while  a  decided  impression  is  made  on  the  disease,  if 
indeed  it  be  not  entirely  removed. 

Another  reason  has  been  mentioned  for  preferring  local  to  general 
bleeding, — it  is  the  difficulty  of  finding  a  vein  in  the  arm  ;  this  diffi- 
culty, with  a  little  care  and  practice,  need  not  exist.  If,  after  apply- 
ing the  bandage,  that  part  of  the  arm  where  the  vein  lies  be  gently 
pressed  and  kneaded  in  order  to  empty  the  cellular  tissue  lying  over 
it,  the  vessel  in  a  little  time  will  be  brought  near  the  integuments, 
and  may  be  distinctly  felt,  if  not  seen  ;  the  practitioner  will  scarcely 
if  ever  be  baffled  if  this  practice  be  adopted.  A  vein  on  the  back  of 
the  hand  may  often  be  found,  if  there  should  be  any  difficulty  in  find 
Ing  one  in  the  arm  ;  or  a  vein  may  be  found  in  the  foot.  In  very 
young  children,  a  leech  applied  to  the  back  of  the  hand  after  banda- 
ging the  arm,  will  often  answer  perfectly  well  in  abstracting  a  suffici- 
ent quantity  of  blood  in  a  short  time.  In  a  case  of  recent  occurrence, 
where  a  sudden  pulmonary  congestion  on  the  third  day  after  birth 
threatened  the  life  of  the  infant,  the  writer  applied  a  large  leech  to 
the  hand  with  complete  success  ;  shortly  after  the  separation  of  the 
leech  the  child  became  faint,  a  little  breast  milk  was  given  with  a 
spoon,  it  very  soon  revived,  when  the  disease  was  entirely  removed 
without  any  other  means. 

These  remarks  on  general  bloodletting  are  not  intended  to  express 
an  opinion  counter  to  the  use  of  topical  bleeding,  for  that  method  is 
often  an  important  addition  to  our  resources,  and  sometimes  indeed 
the  only  means  in  our  power  of  combating  inflammatory  action, 
where  venesection  would  be  decidedly  hazardous.  The  method  rec- 
ommended by  the  author  of  applying  leeches  to  the  axilla,  in  severe 
congestion  of  the  lungs,  has  been  used  by  the  writer  with  very  prompt 
removal  of  all  the  symptoms  ;  it  has  a  decided  advantage  over  any 
other  part,  from  the  immediate  connexion  of  the  axillary  plexus 
with  the  seat  of  the  disease. 

Since  the  above  remarks  were  prepared  for  the  printer,  the  writer 
has  read  with  great  pleasure  the  excellent  lectures  on  bloodletting 
by  Henry  Clutterbuck,  M.  D.,  republished  in  Bell's  Select  Medical 
Library,  in  the  No.  for  May,  1839.  The  following  truly  judicious 
observations  of  Dr.  Clutterbuck,  show  the  opinion  of  the  able  author 
on  the  subject  of  bleeding  infants  : 

"As  to  age,  there  is  hardly  any  that  absolutely,  and  in  all  cases, 
precludes  the  use  of  bloodletting ;  for  no  age  is  exempt  from  the  dis- 
eases and  injuries  which  (in  their  very  nature,  it  might  be  almost 
said,)  call  for  the  use  of  this  remedy.     You  must  not,  for  instance, 


APPENDIX.  677 

adopt  the  notion  so  commonly  entertained,  that  infancy  is  a  state 
of  weakness  that  does  not  allow  of  the  use  of  bloodletting.  Strength 
and  weakness  in  living  beings  have  been  looked  at  in  too  narrow  a 
point  of  view,  and  measured  chiefly  by  muscular  power.  Thus  it 
is  said  that  a  man  is  strong  and  a  child  weak  ;  and  that  a  horse  is 
stronger  than  a  man,  and  so  on  ;  strength,  however,  in  living  beings^ 
is  to  be  measured  by  the  more  or  less  perfect  performance  of  the 
different  functions  of  life  in  the  aggregate.  In  this  sense  strength  is 
synonymous  with  perfect  health.  Physiologically  and  also  medical- 
ly speaking,  the  strength  of  infants  not  only  equals,  but  exceeds, 
that  of  adults.  Vitality  is  greater  in  early  life  than  at  later  periods ; 
all  the  actions  of  life,  whether  healthy  or  morbid,  are  then  perform- 
ed with  greater  energy.  In  infants,  for  example,  inflammation  is 
both  more  frequent  and  more  active  than  in  adults  ;  and  it  runs  its 
course  more  rapidly,  through  its  different  stages  to  disorganization 
and  death.  Greater  promptitude  and  activity  of  treatment  are  there- 
fore necessary  in  the  application  of  remedies  in  early  life,  and  of 
bloodletting  among  the  rest,  when  called  for  by  the  circumstances  oi 
the  case." 

OCCLUSION    OF    THE    RECTUM. 

Note  to  page  283. 

An  interesting  case  of  this  malformation  recently  occurred  to  the 
writer. 

The  lady  of  Mr.  J.  P ,  of  this  city,  was  delivered  o(  a  male 

child,  on  the  12th  of  June,  1839.  He  was  to  appearance  in  perfect 
health,  and  it  was  not  until  the  next  day  that  any  disordered 
state  of  his  system  was  manifested.  The  nurse  then  stated  that  he 
had  passed  no  meconium,  and  appeared  to  be  much  distressed 
with  nausea.  Laxative  enemata  were  directed  to  be  used ;  a 
teaspoonful  of  castor  oil  had  previously  been  given  by  the  nurse 
and  rejected  ;  on  making  a  visit  in  the  evening  of  the  same  day,  it 
was  ascertained  that  great  difficulty  had  been  experienced  in  giving 
the  injection.  The  nausea  and  vomiting  had  increased,  no  meconi- 
um had  been  voided  ;  and  on  examining  the  abdomen  it  was  found 
swelled  and  tense.  Suspecting  that  there  existed  some  obstruction 
in  the  intestinal  canal,  an  examination  was  made  of  the  condition  of 
the  rectum  ;  the  anus  was  found  perfect,  but  an  obliteration  was  dis- 
covered about  three  quarters  of  an  inch  from  the  sphincter;  vari- 
ous-sized elastic  bouges  were  introduced,  to  ascertain  the  existence 

73 


578  APPENDIX. 

of  a  passage  and  to  dilate  it  if  one  could  be  found,  but  not  the  slight- 
est opening  could  be  detected  even  with  a  small  probe. 

On  ascertaining  this  condition  of  the  part,  the  nature  of  the  mal- 
formation was  explained  to  the  parents,  and  its  inevitable  conse- 
quence, the  death  of  the  child,  announced,  unless  relieved  by  an 
artificial  opening,  which  at  the  same  time  it  was  told  them  was  uri 
certain,  from  the  impossibility  of  ascertaining  the  extent  of  the  ob- 
literation. Dr.  Richard  K.  Hoffman  was  requested  to  visit  the 
patient ;  who,  upon  a  careful  examination,  coincided  in  the  opinion 
previously  expressed,  and  recommended  an  operation,  as  affording 
the  only  chance  of  saving  the  child's  life.  Having  obtained  the 
consent  of  the  parents,  he  immediately  introduced  a  common  trocar 
into  the  rectum,  and  passed  up  to  the  obliterated  portion  ;  this  was 
found  to  be  tough  membrane,  and  some  force  was  required  to  pass 
the  instrument  through.  The  meconium  immediately  flowed  out  on 
withdrawing  the  instrument,  accompanied  with  a  quantity  of  thick 
purulent  fluid.  Injections  were  given,  and  the  bowels  kept  open  by 
their  use.  He  continued  to  have  offensive  discharges  for  a  week 
afterwards.  At  the  time  of  writitng  this,  (July  26th,)  he  is  perfectly 
well  and  in  a  thriving  condition. 

COLIC. 

Note  to  page  328. 

Colic  is  a  very  distressing  disorder  in  young  infants,  and  in  some 
it  is  of  daily  occurrence  for  a  long  period  ;  the  contraction  of  their 
limbs  and  violent  cries,  which  nothing  for  the  time  can  stop,  attest 
the  severity  of  their  sufferings.  For  the  most  part  it  arises  from 
badly-digested  food,  where  the  child  is  artificially  fed ;  at  other 
times  it  will  be  produced  by  the  quality  of  the  milk  of  the  mother  or 
nurse,  where  she  is  affected  with  some  physical  derangement,  or  an 
irritable  or  passionate  temper  ;  when  the  latter  is  the  cause,  the  par- 
oxysm has  not  unfrequently  terminated  in  convulsions.  Although 
the  disease  is  not  one  of  danger,  yet  the  great  and  frequent  suffering 
demands  the  attention  of  the  physician.  It  is  attended  in  almost  ev- 
ery instance  with  a  great  degree  of  flatulence,  and  relief  is  instantly 
experienced  on  the  spontaneous  discharge  of  gas  from  the  bowels. 
It  sometimes  arises  from  cold,  and  by  allowing  the  extremities  to 
continue  a  long  time  wet ;  when  this  is  the  cause  there  is  no  flatu- 
lence, and  the  proximate  cause  appears  to  be  an  increjised  action  of 
the  vessels  of  the  mucous  membrane,  bordering  on  inflammatory 
action. 


APPENDIX.  579 

In  the  treatment  of  this  disease,  attention  should  be  paid,  in  the 
first  place,  to  the  quality  and  quantity  of  the  food,  and  alteration 
should  be  made  in  the  diet  of  the  nurse,  if  the  child  be  nourished  ex- 
clusively by  the  breast.  As  there  is  often  acidity  attending  it,  an 
ant -acid  laxative  mixture  will  be  necessary,  with  an  antispasmodic 
combined.  An  occasional  emetic,  where  the  child  is  brought  up 
with  the  spoon  or  bottle,  will  be  required,  for  the  removal  of  the 
undigested  matter.  An  enema  of  an  infusion  of  catnip  or  chamo- 
mile flowers  will  often  afford  immediate  relief  in  a  violent  paroxysm 
of  colic.  In  addition  to  these,  especially  where  the  exciting  cause 
appears  to  be  cold  or  wet,  fomentations  of  warm  water  applied  to 
the  abdomen  with  a  flannel,  or  frictions  applied  to  this  part  with  the 
hand,  while  the  feet  are  immersed  in  warm  water,  will  produce  a  re- 
vulsion to  the  surface.  Suitable  formulae  will  be  found  at  the  end  of 
the  appendix. 

FUNCTIONAL    DISORDERS    OF    THE    LIVER. 

Note  to  page  336. 

Derangements  of  the  functions  of  the  liver  are  not  to  be  ques- 
tioned, because  there  exists  nothing  uniform  in  its  condition  or  in 
that  of  its  secretion.  For  it  is  an  acknowledged  truth,  that  functional 
derangement  may  exist  without  any  alteration  in  the  appearance  of 
the  organ.  Anatomical  changes,  for  instance,  in  the  mucous  mem- 
brane of  the  primae  viae,  are  often  very  various,  and  in  some  instances 
do  not  exist  in  intestinal  fluxes.  Andral  observes,  "  the  researches  of 
modern  anatomists  have  clearly  proved  that  there  are  certain  cases  in 
which  dissection  cannot  discover  any  appreciable  alteration,  either 
in  color,  thickness,  or  consistence  of  the  intestinal  parietes,  or  the 
appearance  of  the  follicles,"  and  "  that  its  appearance  after  death 
does  not  lead  to  any  certain  knowledge  of  the  functional  derange- 
ment with  which  it  had  been  aflected  during  life."  (Path.  Anat.) 
And  Mons.  B.  remarks  that  diarrhoea  of  infants  will  often  rise  from 
simple  augmentation  of  the  follicular  apparatus,  without  inflamma- 
tion or  other  lesion. 

It  is  acknowledged  by  all  who  have  made  investigations  in  hepatic 
affections,  that  there  is  scarcely  any  thing  of  greater  frequency,  both 
in  infants  and  adults,  than  to  find  no  departure  from  the  healthy  ap- 
pearance of  the  liver,  even  after  the  most  serious  affections,  unques- 
tionably connected  with  derangements  of  that  organ ;  and,  on  the 
other  hand,  it  is  said  by  those  who  have  practised  in  India,  that  pa- 


580  APPENDIX. 

tients  will  die  suddenly  from  abscess  of  the  liver  without  suspicion  of 
the  disease  existing. 

HEPATIC   AFFECTIONS BILIOUS    DIARRHCEA CHOLERA   INFANTUM. 

Note  to  pp.  331—340. 

The  remark  of  M.  Broussais,  "  that  it  is  necessary  not  to  general- 
ize too  much  the  observations  made  in  this  country,"  (France,)  is 
particularly  applicable  to  the  diseases  in  question.  The  author 
doubts  the  fact  that  heat  irritates  the  liver  and  causes  an  altered 
state  of  its  secretion.  It  is,  however,  not  difficult  to  prove  that  ca- 
loric will  often  produce  a  great  derangement  of  the  functions  of  this 
organ,  frequently  ending,  as  is  shown  by  dissection,  in  extensive  dis- 
organization. The  effect  of  this  agent  was  long  since  remarked,  for 
Celsus  observes,  "  omnis  calor  et  jecur  et  lienem  inflammat."  (Lib. 
ii.  c.  1.)  And,  at  the  present  time,  the  great  prevalence  of  hepatic 
affections  in  tropical  climates,  and  their  almost  entire  absence  in 
colder  regions,  are  well-known  truths ;  and  scarcely  a  doubt  can 
exist  that  it  is  to  the  influenee  of  atmospheric  heat  that  these  dis- 
eases, so  common  in  hot  climates,  are  principally  to  be  attributed. 
Natives  of  India  experience  to  a  greater  or  less  degree  the  derange- 
ments of  the  liver,  and  Europeans  who  reside  for  any  length  of  time 
in  that  country  suffer,  in  almost  every  instance,  from  them,  in  some 
form  ;  and  all  authors  who  have  directed  their  attention  to  the  sub- 
ject agree  in  attributing  them  to  the  heat  of  the  climate,  and  in  con- 
sidering that  it  is  from  this  cause  that  the  liver  ceases  to  perform  its 
functions  in  a  normal  manner.  This  opinion  is  not  confined  ex- 
clusively to  English  authors,  Johnson,  Moseley,  Thomas,  and  others, 
who  have  resided  in  those  climates ;  for  the  writer  just  quoted  con- 
siders atmospheric  heat  as  an  efficacious  agent  in  the  morbid  devel- 
opment of  the  spleen  and  liver,  "  to  such  a  degree,  that  a  physician 
who  has  practised  in  temperate  climates  alone, will  find  it  difficult  to 
believe."*  Baron  Larrey  also  noticed  the  prevalence  of  hepatitis  in 
Egypt,  and  referred  it  to  atmospheric  heat.  M.  Villela,  who  resided 
a  long  time  in  South  America,  says,  in  a  letter  inserted  in  Broussais' 
Chronic  Phlegmasia,  "  I  venture  to  say  that  disease  of  the  liver  and 
spleen  are  as  common  in  those  countries  as  those  of  the  lungs  are 
here  ;"  and'  assigns  *'  the  extreme  heat  and  immoderate  use  of  brandy 
in  some  and  spices  in  others,"  as  a  cause  of  derangements  of  the 
liver.j     Now,  if  there  exist  any  analogy  between  the  hepatic  affec- 

♦  Broussais'  Chronic  Phlegmasia,  v.  ii.,  p.  282,  translated  by  Drs.  Hays  and  Griflith. 
t  Page  285. 


APPENDIX.  581 

tions  of  one  climate   and  the  pulmonary  disorders  of  another,  it 
appears  to  be  illogical  to  refer  the  one  class  to  the  action  of  another 
cause,  independently  of  climatorial  influence,  while  for  the  production 
of  the  other  none  is  found  necessary  ;  and  Dr.  Johnson  asserts  that 
it  is  well  known  that  spices  of  all  kinds  may  be  devoured  in  vast 
quantities  without  producing  any  effect  on  the  liver  ;  but  spirituous 
liquors,  he  adds,   and  the  correctness  of  his  remark  is  well  known, 
will  produce  a  disordered  change  in  the  functions  and  ultimately  in 
the  structure  of  that  organ.     Atmospheric  heat,  however,  from  the 
testimony  of  others,  is  of  itself  suflicient  to  produce  hepatic  de- 
rangements :  Dr.  Saunders  observes  that  they  are  "  the  spontaneous 
efl^ects  of  a  warm  climate  on  healthy  constitutions,   independently  of 
any  intemperance."*     Dr.  Beddoes  mentions  that  he  was  informed 
by  an  officer  from  the  place  where  the  occurrence  happened,  that 
nearly  all  the  men  belonging  to  a  regiment  died  within  a  short  space 
of  time  of  diseases  of  the  liver,    because  the  commanding  officer 
would   persevere  in  exercising   them  where  the  sun  was  shining. f 
Mr.  Fitzgerald,  who  practised  long  and  very  extensively  at  Madras, 
and  had  "  endless  opportunities  of  seeing  the  disorder  of  which  he 
speaks,"  mentions,  in  an  appendix  to  Dr.  Beddoes'  essay,  that  it  is 
necessary  to  avoid  exposure  to  the  sun,  for  all  detachments  of  sol- 
diers that  were  thus  exposed  suffered  greatly  from  affections  of  the 
liver,   and   some  even  lost  the  greater  portion  of  their  men  from 
this  cause.     He  adds,  "  that  the  natives  of  India  sometimes  suffer  in 
very  hot  seasons  from  acute  inflammation  of  the  liver,  without  the 
assistance  of  intemperance,  to  which  they  are  very  rarely  addict- 
ed."J     Quadrupeds,  as  dogs,  that  are  not  exposed  to  the  eflJects  of 
stimulating  aliments  or  drinks,  or  condiments  used  by  man,  experi 
ence  in  India  the  influence  of  the  usual  morbific  cause  of  disease, 
and  are  aflfected  with  endemic  hepatitis. §     In  the  case  of  children, 
who  are  liable  to  hepatic  affections  in  a  heated  atmosphere  as  well 
as  adults,  and  who  are  not  exposed  to  the  effects  of  stimulating  food 
or  drinks,   when  they  are  disordered  in  the  hepatic  system  in  tropi- 
cal climates,  or  in  the  intensely  hot  summers  of  some   temperate 
climates,   these  derangements  must  arise  from  heat  alone,  and  they 
necessarily  experience  greater  disorders  from  this  cause  ;  for,  as  M 
Billard  justly  observes,  they  are  much  more  susceptible  to  the  influ 

*  Saunders  on  the  Bile,  p.  149. 

t  Beddoes'  Hygeia,  v.  2,  essay  8.     Bristol,  1802. 

t  Appendix  to  Beddoes'  Hygeia. 

§  Johnson  on  Trop.  CHm. 


682 


APPENDIX. 


ence  of  external  agents  than  adults ;  and  it  should  be  noted  that 
diarrhceal  affections  and  hepatic  disorders,  which  are  so  prevalent 
among  children  during  our  summer  and  autumn,  are  rarely  seen  at 
any  other  season,  at  least  as  epidemics.  The  intestines  of  those  in- 
dividuals who  have  died  suddenly  from  intense  heat  are  almost  in 
every  instance  filled  with  bile. 

It  would  be  impossible  to  insert  in  this  limited  space  any  considera- 
ble portion  of  the  facts  which  may  be  gathered  from  various  sources 
upon  this  subject ;  enough  has  been  said  to  prove  that  heat  does  affect 
the  functions  of  the  liver ;  the  authors  already  quoted,  with  others, 
may  be  consulted  for  more  extended  information.* 

The  question  here  naturally  arises,  how  does  an  increase  of  at- 
mospheric temperature  produce  these  effects  ?  This  is  difficult  to 
explain  in  a  satisfactory  manner.  It  may  be,  by  the  directly  stimu- 
lating effect  of  heat  upon  the  circulatory  system  ;  and  the  part 
which  has  a  more  than  ordinary  supply  of  blood,  would  first  experi- 
ence the  effect  of  the  expansion  of  the  fluids  :  the  liver,  it  must 
be  remembered,  possesses  two  sets  of  bloodvessels  for  nutrition  and 
secretion,  and  from  this  circumstance  would  be  the  first  to  feel  the 
effects  of  heat.  Dr.  Johnson,  after  long  and  attentive  observation, 
refers  it  to  a  synchronous  action  existing  between  the  cutaneous  ves- 
sels and  those  of  the  liver,  and  that  when  the  former  are  excited  by 
the  influence  of  heat,  the  latter  also  experience  an  increase  of 
action  ;  the  simultaneous  excitement  of  these  parts  according  to  this 
view  furnishes  an  explanation  of  the  manner  in  which  atmospheric 
heat  acts  on  the  biliary  secretion ;  the  illustrations  are  striking,  but 
too  numerous  for  any  other  mention  than  a  reference  to  them  ;t 
the  idea,  however,  is  not  free  from  objection. 

In  support  of  the  view  of  the  coexistence  of  a  simultaneous 
action  in  these  remote  parts,  it  is  worthy  of  remark  that  erysipelas 
is  often  present  in  affections  of  the  liver,  and  the  species  of  acne  in 
the  nose  and  face  is  almost  a  sure  indication  of  the  congestion  of 
the  hepatic  system. 

All  glands  under  a  certain  state  of  excitement  secrete  an  increased 
quantity  of  their  peculiar  fluids,  some  indeed  to  a  prodigious  amount ; 
and  why  should  the  liver, — a  gland  of  the  largest  size,  and  one 
which  from  its  complicated  structure  and  double  circulation  must  be 

*  Johnson  on  Trop.  Clim.  Saunders  on  the  Liver.  Cleghorn  on  Dis.  of  Minorca. 
Lind  on  Hot  CUm.  Moseley  on  Trop.  Clim.  Curtiss  on  Dis.  of  Ind.  Chisholm  on 
Trop.  Clim.    Clark  on  Dis.  of  E.  and  W.  Indies. 

t  Johnson  on  Trop.  Clim.,  vol.  i.,  pp.  29 — 220. 


APPENDIX. 


S8^ 


liable  to  derangement, — be  not  frequently  disordered  in  its  function 
of  secretion  ?  We  cannot  hesitate  in  believing  that  it  may  some- 
times be  thus  deranged ;  and  when  the  organ  is  excited  to  excessive 
secretion,  it  is  evident  that  the  only  means  we  possess  of  judging  of 
the  existence  of  this  disorder,  is  by  the  presence  of  its  secretion  in 
the  fasces,  and  when  excessive,  by  its  appearance  on  vomiting.  The 
existence  of  bile  in  the  faeces,  and  from  which  they  usually  receive 
their  color,  is  unquestionable;  for  the  experiments  of  Magendie  show 
that,  although  the  digestion  of  food  was  not  interrupted  by  tying  the 
ductus  choledicus,  yet  the  stercoraceous  matter  was  destitute  of  its 
usual  color.  When  therefore  there  is  an  absence  or  an  increase  of 
color  in  the  faeces,  it  may  I  think  be  safely  attributed  to  an  absence 
or  increase  of  the  usual  coloring  matter  of  the  stools ;  unless  we 
have  reason  for  believing  that  some  other  cause  exists.  It  appears 
to  be  less  rational  to  believe,  in  the  instance  related  by  Dr.  John- 
son,* of  the  crew  of  a  ship  saihng  south,  who  were  affected  with 
diarrhoea,  where  the  evacuations  changed  from  a  light  color  to  a 
yellow,  that  it  was  an  alteration  in  the  color  of  the  intestinal  secre- 
tion, than,  with  the  facts  before  us,  of  the  ordinary  source  of  colored 
faeces,  to  consider  it  as  an  excess  of  this  coloring  matter. 

When  an  augmentation  of  secretion  occurs,  there  appears  generally 
to  be  an  altered  and  often  an  irritating  quality  imparted  to  the  se- 
creted fluid,  and  inflammatory  irritation  uniformly  occasions  a  vitia- 
tion of  the  fluid  secreted.  The  tegumentary  tissue  exhibits  an  alter- 
ation in  the  fluids  that  are  secreted  from  it,  when  in  a  state  of  inflam- 
mation, and  the  discharge  from  the  inflamed  part  frequently  produces 
excoriations  on  the  healthy  skin :  the  secretion  from  the  nose  also  is, 
when  excessive,  sometimes  of  a  highly  acrid  nature  ;  I  once  had  a 
lady  under  my  care  who  was  frequently  affected  with  catarrh,  where 
the  discharge  was  of  so  corrosive  a  nature  as  to  destroy  the  texture 
of  the  handkerchiefs.  The  alteration  in  the  properties  of  mucus 
secreted  from  inflamed  surfaces,  is  sometimes  appreciable  by  chem- 
ical tests  ;  that  of  the  nose  becoming  alkaline,  and  changing  vegeta- 
ble blues  green,  while  that  of  the  intestines  is  acid,  and  the  anus  is 
often  found  excoriated  in  affections  of  the  bowels,  especially  in  chil- 
dren. It  might  therefore  be  expected,  d  priori,  that  so  complicated 
a  fluid  as  the  bile  would  not  be  exempted  from  the  general  law,  but 
that  it  also  would  occasionally  undergo  some  change  ;  and  Andral 
has  found  that  the  bile,  although  in  some  instances  so  harmless  that 

*  Johnson  on  the  Liver,  p.  66. 


684  APPENDIX. 

it  might  be  "  touched  and  tasted  with  safety,"  yet  under  other  cir- 
cumstances "  it  caused  pustules  and  ulcers  on  the  tongue  and  lips, 
and  when  introduced  into  the  living  body  has  produced  more  serious 
consequences,  even  death  itself."*  Dr.  Johnson  also  observes  that 
the  color  and  taste  of  the  bile  are  sometimes  surprisingly  altered, 
it  being  of  all  colors,  from  bottle  green  to  jet  black,  and  has  been 
so  acrid  as  to  set  the  teeth  on  edge.f  Dr.  Rush  has  likewise  no- 
ticed the  irritating  quality  of  the  bile,  in  producing  excoriations  on 
the  skin  of  those  engaged  in  dissection.  If  bile  can  become  thus 
irritating  in  quality,  a  diarrhoea  must  of  necessity  ensue  ;  for  in  an 
ordinary  and  healthy  state  of  this  secretion,  it  excites  a  discharge 
of  intestinal  fluids,  as  is  proved  by  the  great  dryness  of  the  faeces 
where  but  little  bile  is  secreted,  and  cases  where  the  bile  duct  has 
been  tied. 

The  author  questions  the  fact  of  the  production  of  a  green  color 
by  a  mixture  of  bile  with  acid,  but  experiments  prove  that  nothing 
is  more  certain ;  and  that  this  result  with  some  kinds  of  acid  is  uni- 
form ;  while  it  is  readily  admitted  that  there  may  be  other  causes 
occasionally  existing,  to  which  an  altered  color  of  the  faeces  may  be 
attributed.  The  experiments  of  Tiedemann  and  Gmelinf  show  that 
when  nitric  acid  is  added  to  bile  of  every  kind,  it  first  becomes 
green,  then  blue  and  violet,  and  afterwards  red. 

Dr.  Maclurg,  of  Virginia,  some  years  ago  made  a  great  number 
of  experiments  on  human  bile  :  he  remarks,  "  one  of  the  most  curi- 
ous circumstances  attending  the  mixture  of  the  mineral  acids  with 
bile  is  the  production  of  a  fine  green  color." 

In  experiment  No.  1,  he  tried  the  effect  of  sulphuric  acid,  which, 
"being  poured  upon  some  bile,  produced  an  instantaneous  coagula- 
tion of  it.  The  coagulum,  swimming  in  a  clear  liquid,  was  then  of  a 
pale  color,  as  well  as  the  liquor  about  it ;  and  on  shaking  the  vessel 
the  coagulum  disappeared,  and  there  was  formed  a  turbid  green 
solution." 

Muriatic  and  nitric  acids  also  "  produced  a  deep  green  color." 

Experiments  were  also  made  with  acetic  and  citric  acids,  which 
produced  no  other  change  than  a  coagulation,  and  a  deeper  yellow 
resembling  the  yolk  of  an  egg.^ 

*  Andral's  Pathological  Anatomy,  translated  by  Drs.  Townsend  and  West, 
t  Johnson  on  Trop.  Clim.    Vol.  i.,  p.  32. 
t  Edinburgh  Med.  and  Surg.  Journal,  Oct.,  1827. 

§  Experiments  upon  the  Human  Bile,  by  James  Maclurg,  M.  D.  London,  1772. 
p.  11,  et  seq. 


APPENDIX.  585 

I  have  repeated  these  experiments  on  human  bile  with  muriatic 
acid,  which  it  is  said  by  Beaumont,  Lauret,  and  others,  to  be  the  acid 
found  in  the  human  stomach,  with  precisely  the  same  result ;  a  green 
color  was  produced  both  on  inspissated  and  diluted  bile.  The  ex- 
periments were  repeated  also  with  acetic  acid  on  diluted  bile,  but  no 
cliange  was  perceptible. 

It  may  be  objected  to  these  experiments  that  they  are  not  made 
where  vitality  controls  the  operations  of  the  economy,  and  that  the 
same  results  may  not  occur  within  the  body  ;  but  the  action  of  vi- 
tality, how  much  soever  it  may  control,  does  not  destroy  the  opera- 
tions of  other  natural  laws, — that  of  the  rarefaction  of  fluids  continues 
the  same,  and  the  chemical  action  of  an  acid  on  an  alkali  is  familiar 
to  every  one.  M.  Billard  questions  the  fact  of  the  neutralizing  effect 
of  the  bile ;  but  it  is  certainly  proved  by  the  experiments  of  Dr. 
Prout,  who  placed  a  piece  of  litmus  paper  through  the  pylorous,  and 
found  the  portion  in  the  stomach  become  red,  while  that  in  the  in- 
testine remained  unaffected.* 

The  existence  of  acid  in  the  intestines,  and  the  effect  it  has  on  the 
bile,  is  shown  in  the  dissection  of  a  child  that  died  of  cholera  infantum, 
made  by  Dr.  Horner,t  in  which  disease  there  is  often  some  bile  se- 
creted, although  in  general  there  is  a  suspension  of  it.  "  Yellow 
bile,"  he  says,  "  was  found  in  the  jejunum,  but  green  in  the  colon  ;" 
to  explain  which  phenomenon  he  adds,  "  we  know  that  frequently  in 
cholera  the  alvine  discharges  are  in  a  state  of  fermentation,  and  are 
sour ;  is  this  process  confined  to  the  colon  ?  if  so,  the  rationale  is, 
that  the  bile  retains  its  natural  color  in  the  small  intestines,  but  be 
comes  green  in  the  large,  from  meeting  there  with  ascescent  matters, 
made  so  by  fermentation." 

The  presence  of  acid  in  the  digestive  fluids  is  also  shown  by  the 
experiment  of  Muller  and  Schwan ;  and  that  it  is  the  muriatic  acid, 
is  proved  by  the  suspension  of  the  digestive  process  on  neutralizing 
it,  and  by  the  restoration  of  this  process  on  the  addition  of  a  proper 
quantity  of  muriatic  acid. J 

From  this  rapid  view  of  the  subject,  it  appears,  1st,  That  the  liver 
may  be  irritated  by  atmospheric  heat ;  2d,  That  its  secretion  may  be 
augmented  ;  3d,  That  the  bile  may  become  changed  in  its  qualities  ; 
4th,  That,  when  so  changed,  it  will  excite  a  greater  flow  of  intestinal 

*  Human  Physiology,  by  Dr.  Hliotson,  part  i.,  p.  102 — 5th  London  edition. 
t  Horner's  Pathol og.  Anat.,  p.  171. 

t  Elements  of  Physiology,  by  J.  Muller,  M.  D,,  translated  from  the  German  by 
Wm.  Bayley,  M.  D.,  London,  1838.     p.  545. 

74 


686  APPENDIX. 

secretion ;  and  5th,  That  one  of  the  causes  of  an  altered  color  in 
bile  is  the  presence  of  acid. 

Diarrhoea  with  discharges,  which  we  must  still  consider  as  pro- 
ceeding from  an  increased  action  of  the  liver,  it  is  well  known  sel- 
dom occurs  during  the  cold  seasons  of  the  year,  but  is  found  to 
prevail  extensively  where  a  high  atmospheric  temperature  exists. 
The  discharges  are  abundant,  and  of  a  green  or  yellow  color.  The 
urine  is  often  colored,  of  a  deep  yellow,  and  the  eye  and  skin  are 
sometimes  tinged  with  the  same  hue.  An  acid  odor  is  frequently 
perceptible  in  the  breath  of  an  infant  affected  with  this  disease,  and 
the  evacuations  are  then  generally  green  ;  and  from  the  actions  of 
the  child,  and  the  relief  usually  experienced  by  pressing  on  the  ab- 
domen, it  appears  to  be  accompanied  with  spasmodic  pain.  If 
these  symptoms  exist,  there  is  every  reason  for  believing  that  a 
morbid  and  irritating  secretion  is  present  in  the  bowels,  which,  from 
the  views  given  above,  will  be  admitted  as  highly  probable.  There 
can  be  no  great  hazard,  as  is  proved  by  most  abundant  experience, 
in  removing  the  acrid  secretion  by  some  mild  purgative,  as  castor- 
oil.  After  this,  there  is  nothing  so  effectual  as  minute  doses  of  calo- 
mel, which,  while  it  produces  in  a  short  time  a  powerful  influence 
on  the  whole  glandular  system,  thus  relieving  the  disease  by  the  res- 
toration of  the  lost  equilibrium,  appears  also,  instead  of  irritating  the 
mucous  membrane  of  the  bowels,  to  allay  its  irritability.  Large 
purging  doses,  on  the  contrary,  are  actually  injurious,  from  the  stim- 
ulating effect  on  the  mucous  membrane.  Whenever  there  is  a  ne- 
cessity for  removing  the  acrid  contents  of  the  bowels,  nothing  is 
better  than  castor-oil,  with  a  few  drops  of  laudanum  combined.  If 
evident  acidity  exist,  which  can  often  be  detected  by  the  odor  from 
the  breath  or  faeces,  an  alkaline  solution  may  be  given  with  advan- 
tage, and  the  drinks  mixed  with  limewater ;  carefully  watching  the 
effects  of  the  latter,  that  the  discharges  may  not  be  checked  by  its 
use,  and  nothing  given  that  will  arrest  the  discharge,  unless  the  color 
become  natural,  when  an  anodyne,  as  Dover's  powder,  maybe  given 
for  that  purpose.  Should  there  be  much  fever  present,  small  doses 
of  ipecacuanha,  combined  with  the  calomel,  will  be  found  use- 
ful. The  existence  of  any  inflammation  in  the  mucous  membrane 
may  be  detected  by  pressure  with  the  flat  of  the  hand  ;  when  this  is 
found  to  be  the  case,  purgatives  of  all  kinds  must  especially  be 
avoided,  and  a  large  emollient  cataplasm  to  the  abdomen  will  be 
found  necessary.  Mucilages  should  at  the  same  time  be  given,  and 
ricewater,  and  milk  and  water,  arrowroot,  thin  sago,  and  other  light 


APPENDIX.  687 

farinaceous  substances  used  for  diet,  according  to  the  age  of  the 
child,  throughout  the  disease,  in  all  its  forms. 

CHOLERA    INFANTUM. 

The  seat  of  this  disease  is  evidently  in  the  mucous  membrane  of 
the  alimentary  canal,  as  has  been  proved  by  dissection  ;  the  affection 
of  this  membrane,  however,  is  not  necessarily  a  primary  disease, 
and  may  depend  for  its  existence  on  some  other  organ  ;  the  consid- 
eration of  the  circumstances  under  which  it  occurs,  and  the  peculiar 
modifications  which  give  it  its  distinctive  character,  may  enable  us 
to  obtain  some  knowledge  of  its  nature.  The  circumstances  which 
are  necessary  to  the  formation  of  cholera  infantum  appear  clearly  to 
be,  as  has  been  stated  by  Drs.  Rush,  Eberle,  and  others,  high  atmo- 
spheric temperature,  a  vitiated  air,  and  the  period  of  primary  denti- 
tion. Neither  of  these  causes  alone,  nor  do  any  two  of  them,  appear 
always  sufficient  for  the  production  of  this  disease  ;  for  it  does  not 
occur  in  the  pure  air  of  the  country,  nor  does  it  prevail  in  crowded 
places  in  cities,  except  in  summer ;  nor  does  it  affect  children  at  any 
other  time  of  life  than  during  the  process  of  teething ;  scarcely,  if 
ever,  showing  itself,  as  Dr.  Eberle  observes,  before  the  third  month, 
nor  after  the  second  year.  Should  it  occur,  as  it  occasionally  does, 
before  the  appearance  of  the  first  teeth,  it  must  be  regarded  as  an 
exception  to  the  general  rule  ;  and  it  then  arises  from  a  cause  which 
will  be  referred  to  after  the  pathology  of  the  disease  has  been  con- 
sidered. 

That  the  liver  has  an  important  agency  in  the  formation  of  this 
affection,  or,  at  least,  that  it  is  materially  connected  with  it,  is  evi- 
dent, from  the  great  size  and  the  dense  and  altered  structure  it  ac- 
quires, as  exhibited  in  cases  which  have  been  examined  after  death. 
Dr.  Horner  observes  that  the  liver  in  cholera  infantum  is  generally 
"  enlarged  very  much,  occupying  two  thirds  of  the  abdominal  cav- 
ity."* Dr.  Dewees  states  that  the  liver,  "  under  almost  all  circum- 
stances, is  greatly  enlarged,  so  as  to  occupy  two  fifths  of  the  cavity 
of  the  abdomen.  It  is  merely  distended  or  swollen  by  congestion, 
and  on  this  account  is  more  firm  and  solid  than  natural."!  "The 
liver,"  says  Dr.  Eberle,  "  besides  the  engorged  state  of  its  blood- 

*  Horner's  Patholog.  Anat.,  loc.  cit. 

t  A  Treatise  on  the  Physical  and  Medical  Treatment  of  Children,  by  W.  P.  Dew- 
ees, M.  D.,  p.  400. 


588 


APPENDIX. 


vessels,  is  often  greatly  enlarged,  particularly  in  cases  of  long  con- 
tinuance, and  this  enlargement  is  usually  attended  with  a  manifest 
firmness  of  its  structure."*  "  In  the  abdomen,  the  liver  has  some- 
times been  found  very  large,  so  as  to  occupy  two  fifths  of  that 
cavity."!  This  condition  of  the  liver  appears  also  to  be  connected 
with  a  suspension  of  its  secretion  to  a  greater  or  less  degree.  The 
putrid  and  acid  smell  of  the  stools,  which  is  a  very  remarkable 
symptom,  show  this  ;  for  according  to  the  experiments  of  Tiedemann 
and  Gmelin,  "  the  bile  tends  to  prevent  the  putrefaction  of  the  food 
during  its  passage  through  the  intestines,  because  when  prevented 
from  flowing  into  them,  their  contents  appear  further  advanced  in 
decay  than  in  a  healthy  state."J  It  is  also  evident  from  the  fact  that 
no  disappearance  of  the  symptoms  occurs  until  the  liver  has  fully 
resumed  its  functions.  Dr.  Eberle  says,  "  so  long  as  the  liver  re- 
mains inactive,  and  the  alvine  discharges  free  from  bile,  the  disease 
may  be  regarded  as  still  possessing  all  its  violent  and  dangerous 
tendency,  whatever  abatement  may  occur  in  the  severity  of  the  vom- 
iting and  purging."^ 

Finding  this  state  of  the  liver  existing  in  cholera  infantum,  and 
knowing  that  atmospheric  heat  develops  an  irritated  condition  of 
this  organ,  and  also  that  this  is  one  of  the  essential  causes  of  the  dis- 
ease in  question,  it  might  very  naturally  be  supposed  that  the  liver 
had  some  agency  in  its  production  through  the  medium  of  the  portal 
circulation.  Again,  the  disease  does  not  appear  except  in  a  vitiated 
air.  Malaria  of  marshes  will  cause  affections  of  the  liver,  and  "  gall 
sickness"  is  a  popular  name  for  diseases  arising  from  an  over-excited 
state  of  this  organ,  accompanied  with  an  increased  secretion  of  bile 
in  malarious  situations ;  these  diseases  are  not  confined  to  the  human 
race,  for  hogs  killed  in  the  neighborhood  of  marshes  where  intermit- 
tents  prevail,  have  enlarged  livers.  ||  Cleghorn  and  Sir  J.  Pringle 
have  observed  that  marsh  miasmata  in  warm  climates  produce  their 
principal  effects  on  the  liver,  and  that  hepatic  disorders  prevail  more 
along  the  borders  of  the  great  rivers,  where  an  insalubrity  of  atmo- 
sphere exists.  What  good  reason  is  there  for  believing  that  malaria 
of  cities  may  not,  when  united  to  another  cause,  produce  a  similar 

*  A  Treatise  on  the  Diseases  and  Physical  Education  of  Children,  by  John  Eberle, 
M.  D.,  p.  286, 

t  Remarks  on  Cholera  Infantum,  by  James  Jackson,  M.  D.  N.  E.  Jour,  of  Med. 
and  Surg.,  v.  i.,  p.  24. 

t  Edin.  Med.  and  Surg.  Journal,  1827.  §  Eberle,  p.  285. 

II  Inaugural  Dissert.,  by  E.  G.  Ludlow,  N.  Y.,  1823,  p.  32. 


APPENDIX.  589 

effect  on  the  same  gland  ?  For  the  effect  of  malaria  is  doubtless  pro- 
duced through  the  agency  of  that  part  of  the  system  which  is  more 
immediately  connected  with  the  air,  i.  e.,  the  lungs ;  and  its  action 
probably  arises  either  from  some  deficiency  of  oxygen  in  the  re- 
spired air,  or  from  some  paralyzing  influence  it  possesses.  The  ex- 
periments of  Tiedemann  and  Gmelin,  who  have  investigated  with  great 
ability  every  thing  relating  to  the  liver  and  its  functions,  will  throw 
some  light  on  the  action  of  malaria  on  the  liver,  if  the  opinions 
they  entertain,  in  regarding  this  organ  as  performing  a  function  sup- 
plementary to  that  of  the  lungs,  be  taken  into  consideration.  That 
it  performs  some  other  part  besides  the  secretion  of  a  small  quantity 
of  bile  when  compared  with  the  size  of  the  gland  whence  it  issues, 
is  a  supposition  far  from  being  unreasonable  ;  and  that  its  office  may 
be  that  of  an  assistant  to  the  lungs  is  not  improbable,  as  will  appear 
from  the  following  facts. 

These  experimenters  have  remarked  that  the  size  of  the  liver  is 
not  proportionate  to  the  quantity  of  food  taken,  but  is  inversely  pro- 
portionate to  the  size  of  the  lungs  ;  and  in  warm-blooded  animals  that 
have  large  lungs  and  live  always  in  air,  the  liver  compared  with  the 
body  is  proportionally  less  than  in  those  that  live  partly  in  water. 
They  have  also  shown,  by  many  examples,  that  the  quantity  of  ve- 
nous blood  sent  through  the  liver  increases  as  the  pulmonary  system 
is  less  perfect.  It  is  larger  in  reptiles,  fishes,  and  moluscous  animals. 
It  is  also  proportionally  larger  in  the  human  foetus  ;  and  its  activity 
has  also  been  ascertained  in  hybernating  animals  during  the  suspen- 
sion of  respiration,  when  bile  is  constantly  secreted.* 

From  the  fact  also  of  the  existence  of  a  large  portion  of  carbon  m 
the  resin  of  bile,  it  would  seem  that  the  blood  in  secreting  this  fluid 
parts  with  some  of  its  carbon,  and  if  so,  the  liver  certainly  performs 
a  function,  in  a  degree  at  least  analogous  to  that  of  the  pulmonary 
system. 

We  might  therefore  expect  to  find  an  increased  action  in  the  liver 
whenever  there  is  a  change  in  the  quality  of  the  atmosphere  by  which 
its  usual  active  properties  are  impaired. 

There  then  appears  to  be  two  causes  producing  inordinate  hepatic 
action,  and  a  distension  of  the  organ  is  very  likely  to  ensue  ;  for 
when  there  is  a  large  quantity  of  blood  circulating  in  it,  from  its 
loose  structure  it  is  readily  distended,  as  is  the  case  in  the  foetus ;  and 
indeed  it  more  often  enlarges  than  inflames.    Whenever  also  a  gland 

*  Edinburgh  Med.  and  Surg.  Journal,  loc.  cit. 


690  APPENDIX. 

is  excessively  irritated,  a  suspension  of  its  secretion  often  ensues,  as 
is  daily  seen  in  bronchial  and  other  inflammations ;  and  the  suspen- 
sion of  the  biliary  secretion  occurs  to  a  greater  or  less  degree  in 
cholera  infantum.  From  these  causes  a  congestion  of  the  liver  takes 
place,  which,  obstructing  the  free  passage  of  blood,  the  vena  porta 
thus  becomes  filled,  and  the  parts  whence  it  receives  its  blood  are 
consequently  congested.  These  parts  are  nearly  all  the  abdominal 
viscera,  and  the  blood,  as  is  well  known,  instead  of  being  conveyed 
directly  to  the  heart,  is  collected  into  one  trunk  and  carried  through 
the  liver,  dividing  as  it  passes  into  numerous  branches,  which  are 
again  collected  into  another  trunk  passing  into  the  ascending  cava. 

This  congestion,  however,  is  not  sufficient  of  itself  to  form  the 
disease  in  question,  and  there  must  be  some  reason  for  its  appearance 
only  in  the  mucous  follicles,  as  is  shown  by  the  dissections  of  Dr. 
Horner  to  be  the  seat  of  this  affection,* — some  circumstance  must 
arise  to  fix  it  in  this  part.  The  following  appears  to  be  the  expla- 
nation :  From  numerous  dissections,  M.  Billard  has  demonstrated 
that  at  the  time  of  dentition  there  is  a  general  development  of  all 
parts  immediately  connected  with  digestion,  and  that  the  follicular 
apparatus  of  the  stomach  and  intestines  is  in  a  state  of  excitement, 
and  undergoes  a  remarkable  change  simultaneously  with  the  eruption 
of  the  first  teeth,  secreting  an  abundance  of  mucus,  either  to  assist  in 
the  assimilation  of  the  new  kind  of  food  which  the  infant  will  soon 
require,  or  to  protect  the  mucous  membrane  of  the  intestines  from 
the  irritation  to  which  it  will  thereby  become  exposed. f 

From  the  remarkable  fact,  therefore,  of  the  occurrence  of  the 
disease  at  the  time  of  teething,  when  the  muciparous  follicles  are  in 
a  state  of  exalted  functional  excitability — from  the  enlarged  condition 
of  the  liver  in  almost  every  instance — it  is  evident  that  cholera  in- 
fantum is  a  disease  seated  in  the  mucous  follicles  of  the  intestines ; 
and  that  hepatic  congestion  is  necessarily  connected  with  it ;  the 
disease  of  the  follicles  being  a  secondary  affection,  caused  by  the 
congested  state  of  the  liver,  by  which  a  free  passage  of  blood  is  pre- 
vented ;  the  portal  vein  is  thus  crowded,  and  the  return  of  blood 
from  the  extreme  branches  arrested.  The  natural  development  and 
excessive  action  of  these  follicles  at  the  time  of  dentition,  place  them 
in  a  condition  to  take  on  a  deranged  action  upon  the  occurrence  of 
any  cause  which  would  produce  congestion  in  them  ;  it  is  on  this 
account  that  the  disease  is  fixed  in  this  apparatus  alone,  while  other 

*  Horner's  Pathol.  Anat.,  loc.  cit.  t  p,  386. 


APPENDIX.  591 

parts  of  the  viscera  also  returning  blood  through  the  liver,  not  being 
so  predisposed,  are  exempted  from  the  effects  of  congestion. 

In  addition  to  these  characteristic  symptoms,  there  exists  also  in 
most  cases  a  very  remarkable  heat  about  the  head,  throughout  the 
vhole  of  the  disease ;  this  may  be  explained  to  arise  from  the  great 
tendency  under  any  existing  disease,  at  this  period  of  life,  to  cerebral 
irritation,  from  the  qiiantity  of  blood  circulating  in  that  organ  during 
its  development,  which  M.  Billard  observes  is  not  completed  until 
the  end  of  a  year.  Teething,  to  which  cerebral  affections  are  often 
assigned,  is  probably  but  an  occasional  source  of  additional  irrita- 
tion. 

The  treatment  should  be  mainly  directed  to  the  relief  of  the  glan- 
dular congestion  on  which  the  disease  depends  ;  for  if  once  a  free 
secretion  of  bile  is  obtained,  the  disease  may  almost  be  considered 
as  overcome:  "the  sooner  the  liver  can  be  brought  to  resume  its 
secretory  action,  the  greater  in  general  will  be  the  probable  ultimate 
success  in  our  attempts  to  subdue  the  disease."* 

In  the  forming  and  early  stages  of  the  disease  the  most  obvious 
remedy  is  the  abstraction  of  blood  from  the  right  hypochondrium 
by  means  of  leeches ;  in  conjunction  with  this  remedy  minute  doses 
of  calomel,  as  recommended  by  Dr.  Dewees,  are  the  best  means  of 
fulfilling  the  indication.  Judging  from  experience,  the  use  of  calo- 
mel is  the  most  efficacious  method  of  combating  the  disease  ;  far 
from  increasing  the  irritation  of  the  mucous  membrane,  in  these 
small  doses,  calomel  appears  to  allay  it,  and  a  quiet  repose  often 
follows.  To  this  is  sometimes  added  small  doses  of  ipecacuanha, 
from  its  usefulness  in  creating  a  diaphoretic  action ;  but  the  great 
tendency  to  vomiting  often  forbids  its  use.  When  the  latter  symp- 
tom exists  to  any  great  degree,  a  large  stimulating  cataplasm  of  cam- 
phor ought  to  be  applied  over  the  stomach,  or  frictions  of  tincture  of 
capsicum  and  camphor  with  a  flannel  may  be  used.  Blisters  have 
also  been  found  very  beneficial  by  some  practitioners  to  allay  the 
excessive  morbid  action  of  the  stomach  and  bowels.  Toast  water 
and  an  infusion  of  roasted  Indian  corn,  taken  cold  and  in  small 
quantities,  will  be  found  useful  in  allaying  this  irritability.  Dr. 
Dewees  recommends  injections  of  salt  and  water  for  the  same  pur- 
pose ;  a  revulsive  effect  is  produced  by  their  use,  and  to  the  irritation 
they  occasion  in  the  lower  intestines  is  their  benefit  to  be  attributed  ; 
they  are  the  more  useful  when,  as  is  sometimes  the  case,  but  little 
affection   of  these   intestines   exists.     When  the  irritability  of  the 

*  Eberle   loc,  cit. 


692  APPENDIX. 

Stomach  is  connected  with  acidity,  which  may  generally  be  detected 
by  the  odor  of  the  matters  vomited,  a  few  grains  of  prepared  chalk 
may  be  combined  with  the  calomel ;  other  alkaline  remedies,  and 
the  effervescent  mixture,  will  be  fomid  useful  for  the  same  purpose. 
The  warm  bath  is  a  most  efficacious  adjunct  to  the  usual  remedies 
in  this  disease. 

There  are  often  present  some  symptoms  of  inflammatory  action, 
known  by  a  tenderness  of  the  abdomen  ;  and  when  there  exists  great 
heat  about  the  head,  local  bloodletting,  by  means  of  leeches,  is  indi- 
cated, and  should  not  be  omitted. 

From  the  irritation  which  teething  often  creates,  it  is  a  useful  and 
indeed  a  necessary  operation  to  divide  the  gums  freely  to  the  socket ; 
no  harm  can  ever  result  from  this  practice ;  on  the  contrary,  when  the 
gums  are  swollen,  and  to  appearance  painful,  great  benefit  is  derived 
from  the  operation. 

Dr.  Mann  speaks  very  favorably  of  the  use  of  acetate  of  lead  in 
this  disease  ;*  it  is  evident,  however,  that  so  powerful  an  astringent 
cannot  be  safely  used  until  the  disease  has  passed  through  its  first 
stages,  and  has  assumed  something  of  the  character  of  chronic  diar- 
rhoea ;  and  in  the  diarrhoea  attendant  on  excessive  action  of  the  mu- 
ciparous follicles,  without  inflammation,!  astringents  are  clearly  indi- 
cated. It  is  in  this  stage  of  the  disease  that  infusions  of  nutgalls, 
columbo,  logwood,  pomegranate  bark,  recommended  by  practical 
writers,  are  found  useful ;  and  it  is  in  this  stage  also  that  spirits  of 
turpentine  has  been  found  beneficial,  in  doses  of  from  five  to  twenty 
drops,  three  or  four  times  a  day.J  Dr.  Eberle  and  Dr.  Condie  rec- 
ommend its  use  earlier  in  the  disease,  "  to  check  the  disordered 
action  of  the  stomach."  With  the  recorded  experience  of  these 
gentlemen  it  may  safely  be  regarded  as  a  remedy  for  the  disease 
under  consideration. 

Great  benefit  is  derived  from  the  use  of  mild  astringents  and 
tonics  during  convalescence  ;  the  diarrhoea  being  then  but  a  simple 
and  almost  a  natural  increased  action  of  the  muciparous  follicles, 
from  the  change  in  the  system  at  this  period  of  life.  The  instinct- 
ive desire  for  exciting  food  is  very  remarkable  during  convalescence, 
and  infants  are  often  seen  greedily  sucking  a  piece  of  salted  pork  or 
fish :  the  gratification  of  this  instinct.  Dr.  Rush  observes,  may  be 
allowed,  and  often  with  obvious  relief  to  all  the  symptoms ;  and  Dr. 
Hosack  recommends  the  juice  of  shellfish  during  convalescence.^ 

♦  Vide  New  York  Med.  Repos.,  vol.  ii.,  p.  309.  t  Vide  p.  366. 

t  Dewees,  loc.  cit.  §  Hosack's  Essays. 


APPENDIX.  593 

This  eager  desire  for  stimulating  food  afibrds  a  striking  illustration 
of  the  nature  of  the  disease  here  taken,  and  of  the  inordinate  and 
diseased  development  of  the  parts  that  are  at  this  time  of  life  under- 
going a  change  for  the  reception  of  a  new  kind  of  food.  The  occa- 
sional production  of  the  disease  also  by  the  premature  use  of  solid 
and  stimulating  food,  thus  exciting  into  inordinate  action  the  parts 
which  have  been  pointed  out  as  concerned  in  digestion,  again  illus- 
trates its  pathology. 

The  strictures  of  the  author  on  the  non-success  of  American 
practice  and  prophylactic  treatment  in  cholera  infantum,  are  not  more 
just  than  similar  strictures  would  be  if  applied  to  any  other  disease 
that  baffles  the  skill  of  all  physicians  ;  such,  for  instance,  as  phthisis, 
in  all  countries, — spasmodic  cholera,  in  India,  America,  or  France. 

In  many  diseases,  there  may  be,  and  often  is,  a  limited  view  of 
their  nature,  when  studied  only  as  they  are  manifested  in  one  organ, 
without  considering  the  connexion  it  may  have  with  others,  and  in 
som.e  cases  even  the  absolute  dependance  of  one  organ  on  others  for 
the  continuance  of  its  healthy  functions.  To  the  disease  we  have 
just  been  considering  this  remark  applies  with  more  than  ordinary 
force ;  and  the  extended  view  of  it,  and  the  consequent  treatment 
adopted  in  this  country,  is  the  result  of  a  vast  accumulation  of  expe- 
rience, obtained  where  the  prevalence  of  the  disease  is  coextensive 
with  the  boundaries  of  the  land,  and  where  its  appearance  is  annually 
anticipated  with  the  same  certainty  as  that  of  the  season  which  gives 
it  existence.  Those  who  have  recorded  this  experience  are  men 
who  have  distinguished  themselves  in  the  fields  of  science,  and  who 
are  unsurpassed  in  sagacity,  and  in  the  attainment  of  the  object  of  all 
intellectual  culture  when  applied  to  medical  science, — a  solid  philo- 
sophical judgment.  It  would  be  impossible,  as  it  would  indeed  be 
unnecessary,  to  attempt  to  exhibit  at  length  the  professional  charac- 
ter of  some  of  our  distinguished  countrymen ;  but  a  reference  to  our 
numerous  medical  treatises  may  with  confidence  be  made,  in  proof 
of  the  industry,  erudition,  and  genius  displayed  in  the  cultivation  of 
the  science  of  medical  philosophy. 

SUSPENSION    AND    RETENTION    OF    URINE. 

Note  to  page  351. 

When  it  is  ascertained  that  there  is  a  suspension  of  the  unnary 
secretion,  and  that  the  bladder  is  empty,  we  ought  to  avail  ourselves 
of  those  means  which  will  excite  the  secretory  function  of  the  kid- 
neys.    A  small  quantity  of  infusion  of  parsley  root,  with  a  few  drops 

75 


594  APPENDIX. 

of  Spts.  Nit  D.  will  almost  always  succeed  in  effecting  this  object, 
particularly  if  assisted  with  the  warm  bath  and  enemata. 

Retention  of  urine  immediately  after  birth  not  unfrequently  arises 
from  mucus,  which  may  be  removed  with  a  small  probe.  Fomenta- 
tions with  hops,  or  flannel  dipped  in  warm  water,  and  applied  to  the 
pubic  region,  or  frictions  with  camphorated  oil,  will  often  relieve  it, 
when  arising  from  spasm  of  the  neck  of  the  bladder.  If,  however, 
these  measures  should  not  speedily  relieve  the  retention,  no  time 
should  be  lost  in  vain  attempts  to  relieve  this  dangerous  affection  by 
a  reliance  on  these  applications,  but  a  small-sized  flexible  catheter 
ought  to  be  carefully  passed  into  the  bladder,  as  the  only  efficient 
means  in  our  power  of  procuring  an  evacuation  of  urine. 

It  is  of  great  importance  to  ascertain  the  existence  of  this  disease, 
for  doubtless,  as  Dr.  Dewees  correctly  remarks,  some  infants  have 
perished  from  this  affection  without  its  having  been  suspected.  No 
reliance,  therefore,  should  be  placed  on  the  representation  of  nurses, 
that  the  urine  is  regularly  discharged  ;  but,  when  there  is  reason  to 
suspect  the  disease,  the  physician  ought  carefully  to  examine  the 
abdomen  and  pubic  region  for  the  symptoms  which  indicate  a  reten- 
tion of  urine. 

CROUP. 

Note  to  page  388. 

Having  for  a  number  of  years  been  in  the  habit  of  treating  this 
disease  with  uniform  success,  according  to  the  views  and  principles 
taught  by  the  late  Dr.  David  Hosack,  when  professor  of  the  theory 
and  practice  of  physic  in  the  College  of  Physicians  and  Surgeons  of 
the  University  of  the  State  of  New  York,  the  translator,  by  permis- 
sion, avails  himself  of  the  opportunity  afforded  by  the  publication  of 
the  lectures  of  Dr.  Hosack,  (Philadelphia,  1838,)  to  copy  a  portion 
of  his  lecture  on  the  treatment  of  croup : 

"  Writers  upon  this  subject  differ  as  widely  as  they  do  about  the 
nature  or  character  of  the  disease ;  but  none,  in  my  opinion,  ap- 
pear to  have  sufficiently  discriminated  between  the  different  stages 
in  which  the  remedies  they  severally  recommend  ought  to  be  em- 
ployed ;  even  Dr.  Cheyne's  late  valuable  work,  and  which  contains 
the  best  pathology  of  this  disease,  is  in  some  degree  defective  in  this 
respect.  I  have  been  led  at  the  bedside  to  distinguish  three  distinct 
stages  of  croup :  the  first  may  be  denominated  the  forming  stage 
of  the  disease  ;   in  this  the  affection  is  local ;    the  irritation  has  not 


APPENDIX.  595 

yet  extended  to  the  whole  system  ;  tlie  child  even  sits  laughing  and 
])laying  upon  the  lap  of  its  mother,  manifesting  a  very  unusual  but 
morbid  degree  of  exhilaration  ;  its  skin  is  cool  and  moist,  its  pulse 
not  perceptibly  accelerated  ;  but  its  hoarse,  hollow  sounding,  and 
frequently-returning  cough,  its  wheezing  inspiration,  its  restlessness, 
and  especially  its  cries  after  a  fit  of  coughing,  all  denote,  to  the  phy- 
sician and  parent  acquainted  with  the  disease,  the  consequences  that 
will  soon  ensue,  if  active  means  be  not  employed  to  prevent  the 
second,  or  febrile  stage. 

"  In  this  stage  the  whole  system  partakes  of  the  irritation ;  the 
pulse  is  frequent,  the  skin  hot  and  dry,  the  respiration  hurried,  the 
tongue  covered  with  the  usual  white  fur  indicative  of  inflammation, 
the  lips  and  cheeks  remarkably  florid,  the  cough  frequent,  but  at- 
tended with  a  more  acute  sound  than  that  of  the  first  stage  ;  every 
inspiration,  too,  is  attended  with  more  uniform  wheezing  than  that 
which  appears  in  the  first,  when  occasionally  an  interval  occurs,  in 
which  the  child  breathes  as  if  in  health.  But  in  this  second  stage 
no  such  interval  is  perceived ;  the  trachea,  bronchiae,  and  lungs  be- 
come so  surcharged  by  the  circulating  fluids,  that  the  child  has  not 
even  a  momentary  relief  from  its  oppression  ;  and  in  a  short  time, 
if  left  to  itself,  especially  if  the  patient  be  plethoric,  the  countenance 
exhibits  a  purple,  livid  color,  not  unlike  that  of  apoplexy,  and  is 
even  attended  with  a  degree  of  stupor,  or  propensity  to  sleep.  This 
loaded  state  of  the  lungs,  and  interruption  to  the  free  return  of  blood 
from  the  head,  I  have  frequently  witnessed  in  this  stage  of  croup: 
if  the  patient  be  now  neglected,  or  the  evacuations  be  sparing  and 
insuflicient,  an  effusion  from  the  exhalent  vessels  opening  into  the 
windpipe,  bronchiae,  and  surface  of  the  lungs,  inevitably  takes  place. 
In  the  two  former,  the  eff'used  matter  assumes  a  membranous  ap- 
pearance, probably  owing  to  the  forcible  passing  and  repassing  of 
the  air  through  the  preternaturally  constricted  tubes  ;  but  in  the 
lungs  themselves,  it  appears  in  the  form  of  a  viscid  fluid,  partly 
resembling  both  phlegm  and  pus.  When  this  eflJusion  has  actually 
taken  place,  the  febrile  symptoms  sensibly  abate,  and  sometimes  dis- 
appear altogether  ;  the  child  is  also  apparently  free  from  pain,  but  it 
suflfers  violent  paroxysms  of  cough  and  diflicult  breathing,  attended 
with  an  irregular  and  spasmodic  respiration,  as  in  asthma  or  dropsy 
of  the  chest,  and  with  similar  intervals  of  ease.  These  paroxysms, 
in  young  children,  continue  but  a  few  hours  before  dissolution.  But 
in  children  arrived  at  eight  or  ten  years  of  age,  they  frequently  con- 
tinue several  days."     "  This  stage,  in  which  the  membranous  eflu- 


59B  APPENDIX. 

sion  takes  place,  I  denominate  the  membranous,  or  purulent  stage  ; 
from  this  advanced  state  of  the  disease  recovery  is  so  rare,  that  it  is 
not  to  be  expected  ;  it  might  almost  be  denominated  the  fatal  stage 
of  croup.  These  distinctions  it  is,  in  my  opinion,  important  for  the 
practitioner  to  keep  in  view,  as  they  lead  to  important  conclusions 
in  practice.  They  teach  us,  during  the  first  or  forming  stage  of  this 
disease,  to  adopt  the  most  active  means  of  restoring  the  suppressed 
secretions  of  the  trachea  and  surface  of  the  lungs,  and  by  open  bow- 
els and  perspiration  to  guard  against  the  general  excitement  of  the 
system.  For  this  purpose,  when  called  to  a  patient  laboring  under 
the  first  symptoms,  in  which  the  disease  appears  to  be  confined  to 
parts  primarily  aflfected,  it  is  my  practice  to  administer  an  emetic 
composed  of  tartarized  antimony  and  ipecacuanha  ;  to  a  child  under 
two  years  of  age,  I  direct  from  one  to  two  grains  of  emetic  tartar, 
with  from  five  to  ten  grains  of  ipecacuanha,  every  fifteen  minutes, 
until  it  operates  to  such  a  degree  as  to  induce  a  plentiful  secretion 
from  the  trachea  and  lungs.  It  is  surprising,  in  some  instances  in 
this  disease,  to  see  the  immense  quantity  of  viscid,  ropy  phlegm  dis- 
charged by  the  operation  of  an  active  emetic  at  this  period  of  the 
complaint;  but  when  this  discharge  has  been  accomplished,  and  the 
cough  become  loose,  which  is  an  evidence  of  the  natural  secretion 
being  restored  upon  the  surface  of  the  parts  affected,  we  may,  in 
most  cases,  consider  the  patient  secure  from  danger."  "  In  this 
second  stage  of  croup,  such  is  the  determination  of  the  circulating 
fluids  to  the  part  afiected,  and  such  the  general  febrile  excitement 
of  the  system,  that  the  most  efficient  means  of  diminishing  the  ple- 
thora of  the  bloodvessels,  and  of  diverting  the  irritation  from  the 
part  affected,  become  necessary.  With  this  view,  the  patient  should 
be  bled  freely,  in  proportion  to  its  age  and  powers  of  constitution  ; 
say,  for  a  child  under  two  years  of  age,  from  two  to  four  ounces ; 
from  two  to  six  years,  from  four  to  six  or  eight  ounces,  and  to  be 
repeated  as  the  urgency  of  the  symptoms  may  require."  "  Although 
I  am  not  an  advocate  for  small  bleedings  in  croup,  let  me  here  take 
occasion  to  express  my  disapprobation  of  the  practice  of  some  phy- 
sicians, especially  that  recommended  by  the  late  Dr.  Bayley,  of  this 
city.  Dr.  Ferriar,  of  Manchester,  and  Dr.  Dick,  of  Alexandria,  (see 
third  Supplement  to  Dr.  Barton's  Med.  and  Physical  Journal,  for 
May,  1809,  p.  242,)  I  mean  that  of  bleeding  the  patient  until  faint- 
ing be  produced.  The  relaxing  eflfects  of  bloodletting  upon  the 
system  are  no  doubt  desirable  in  this  complaint,  and  were  probably 
the  objects  which  the  advocates  of  this  mode  of  treatment  had  in 


APPENDIX.  597 

view  ;  but  having  observed,  in  some  instances,  very  serious  and 
permanent  evils  to  the  constitution,  occasioned  by  the  debility  which 
this  profuse  evacuation  had  produced,  and  knowing  that  even  the 
most  violent  attacks  of  croup  will  yield  to  a  less  excessive  evacua- 
tion by  the  lancet  when  conjoined  with  other  remedies,  I  have  hith- 
erto objected  to  this  practice  in  the  extent  it  has  been  recommended. 
After  bloodletting  generally  some  partial  relief  is  immediately  ob- 
tained ;  respiration  is  less  frequent ;  the  peculiar  noise  of  inspiration 
is  also  diminished  ;  the  cough  becomes  more  loose  and  yielding ; 
the  skin  is  rendered  moist,  and  the  pulse  less  tense  and  frequent. 

"  But  these  favorable  symptoms  are  oftentimes  deceptive,  and  of 
short  duration :  the  cough,  labored  respiration,  and  heat  of  skin,  are 
perhaps  all  renewed  in  the  course  of  an  hour.  In  that  case,  the  an- 
timonial  emetic  must  be  immediately  employed.  Although  the  force 
of  the  disease  may  have  been  greatly  subdued  by  bloodletting,  the 
alarming  symptoms  so  frequently  return,  that  I  am  now  in  the  con- 
stant practice  of  prescribing  the  emetic  immediately  after  blood- 
letting has  been  performed,  without  waiting  to  ascertain  the  effects 
which  the  bleeding  alone  might  produce  ;  if,  however,  after  the  oper- 
ation of  tlie  emetic,  the  symptoms  still  continue  violent,  I  usually 
repeat  the  bleeding,  immerse  the  patient  in  a  warm  bath,  apply  a 
large  blister  to  the  throat,  covering  the  larynx  and  trachea,  and  ad- 
minister a  cathartic  of  calomel,  from  five  to  ten  grains,  repeating 
this  medicine  every  two  hours,  until  it  produces  some  sensible  effect 
in  this  respect,  at  the  same  time  soliciting  its  operation  upon  the 
bowels  by  injections  occasionally  administered. 

*'  These  several  remedies  have  been  employed,  and  having  failed 
completely  to  subdue  the  febrile  symptoms,  and  to  divert  the  irrita- 
tion from  the  trachea  and  lungs,  I  next  direct  small  doses  of  calomel 
and  James's  powder,  from  two  to  five  grains  of  each,  to  be  given 
every  two  hours,  to  a  child  under  four  years  of  age ;  but  when  suf- 
ficient evacuation  from  the  bowels  may  have  been  procured,  I  fre- 
quently prescribe  the  antimonial  wine,  or  a  solution  of  tartar  emetic, 
in  such  doses  as  to  excite  a  considerable  degree  of  nausea  and  relax- 
ation ;  with  these  I  occasionally  blend  a  small  portion  of  laudanum, 
where  it  may  be  indicated  either  in  consequence  of  the  profuse  evac- 
uation by  the  bowels,  or  when  the  cough  may  be  very  harassing  to 
the  patient,  which  is  sometimes  the  case  when  the  febrile  symptoms 
are  greatly  moderated ;  in  other  respects  laudanum  should  be  ad- 
ministered with  great  caution  in  this  disease. 

"  The  physician  is  sometimes  called  upon  at  a  late  period  of  the 


598  APPENDIX. 

disease,  where  the  means  which  have  been  described  have  not  been 
employed  ;  or  if  they  have  been,  may  not  have  succeeded,  and  in 
Avhich  the  third  stage  of  the  disease  has  become  apparent.  Respira- 
tion, as  in  the  two  preceding  stages,  is  still  laborious,  accompanied 
with  the  same  wheezing  noise  upon  every  inspiration ;  the  cough 
also  continues  violent,  without  the  least  expectoration,  and  returns 
in  paroxysms,  in  which  the  patient  is  threatened  with  immediate 
suffocation  ;  the  countenance  exhibits  a  blueish  livid  appearance,  at 
the  same  time  that  the  patient  manifests  the  greatest  anxiety  and 
distress  ;  occasionally,  however,  it  has  intervals  of  ease,  in  which  its 
sufferings  are  apparently  inconsiderable ;  but  these  intervals  are  of 
short  duration,  and  afford  no  prospect  of  relief,  for  the  effusion  men- 
tioned, and  the  consequent  formation  of  a  membranous  matter  lining 
the  trachea  and  bronchia,  has  already  taken  place.  In  this  stage  of 
the  disease,  it  has  occasionally  happened  that  portions  of  the  mem- 
brane have  been  thrown  off  by  coughing,  by  which  the  patient  has 
happily  been  preserved."  "  Calomel,  in  small  but  repeated  doses, 
squills,  the  syrup  of  onions,  the  seneka  snakeroot,  ammoniae,  and 
asafoetida,  and  the  vapor  of  vinegar  and  water,  are  the  medicines  in 
which  I  am  inclined  to  place  most  reliance  at  this  advanced  period 
of  croup.  As  they  are  a  class  of  remedies  calculated  to  excite  the 
secretions  from  the  lungs,  without  impairing  the  general  powers  of 
the  system,  they  afford,  if  steadily  persisted  in,  the  means  of  loosening 
and  of  ejecting  the  membranous  matter,  as  well  as  the  fluid  materials 
effused  over  the  surface  of  the  lungs."  "Dr.  Archer,  of  Maryland, 
has  rendered  an  important  service  to  medicine  by  reviving,  not  in- 
troducing, (see  Woodville  Drinker's  remedy,)  into  general  use  the 
polygala  senega,  as  a  remedy  in  croup. 

"  Hitherto,  however,  it  has  certainly  disappointed  the  expectations 
of  most  practitioners,  because  it  has  been  prescribed  indiscriminately 
in  every  stage  of  the  disease ;  whereas,  for  the  very  reason  that  it 
is  so  useful  in  exciting  the  vessels  of  the  trachea  and  lungs  to  a 
powerful  excretion  of  the  materials  oppressing  them  in  the  last  stage 
of  croup,  it  is  certainly  a  hazardous  prescription  when  those  organs 
are  preternaturally  excited,  as  they  are  both  in  the  forming  and  fe- 
brile stages  of  this  disease." 

Vitriolic  emetics  have  of  late  year's  been  much  used  in  the  mem- 
branous stage  of  croup.  Three  cases  under  the  most  unpromising 
circumstances,  successfully  treated  by  sulphate  of  zinc,  are  recorded 
in  the  3rd  volume  of  the  New  York  Medical  and  Physical  Journal. 


APPENDIX.  599 


HOOPINGCOUGH. 

When  there  are  present  any  symptoms  of  inflammatory  action,  it 
is  obvious  that  the  proper  remedy  is  the  abstraction  of  blood  by  the 
lancet  or  by  leeches  ;  and  in  case  of  plethora  with  threatened  con- 
gestion of  the  brain,  bleeding  is  an  important  and  even  a  necessary 
remedy.  When  the  inflammatory  irritation  is  in  some  measure  sub- 
dued, a  sedative  mixture  will  be  found  of  great  efficacy  in  allaying 
the  distressing  fits  of  coughing. 

As  the  child  is  constantly  annoyed  with  a  quantity  of  viscid  mucus, 
emetics  will  be  found  useful,  and  will  almost  always  shorten  the  par- 
oxysm of  coughing ;  small  doses  of  ipecacuanha  or  tartar  emetic 
given  during  the  interval  for  the  purpose  of  allaying  the  febrile 
action,  will  on  the  accession  of  a  cough  often  act  as  an  emetic.  Tar- 
tar emetic  combined  with  testaceous  powder  is  an  old  and  favorite 
prescription.  There  is  evidently  a  disordered  condition  of  the  stom- 
ach and  bowels,  generally  accompanied  with  acidity,  as  the  altered 
state  of  the  secretions  show.  It  will  therefore  be  necessary  to  attend 
to  the  primas  via?,  and  administer  laxatives  throughout  the  disease : 
soda,  rhubarb,  and  ipecacuanha  will  be  found  a  good  combination 
for  this  purpose. 

Narcotics  have  been  found  highly  necessary  in  the  spasmodic  or 
chronic  stage  of  the  disease  ;  and  opium,  conium,  hysoscyamus,  lac- 
tuca,  belladonna,  &c.,  have  all  been  used  with  various  success.  Bel- 
ladonna has  within  a  few  years  been  highly  successful,  in  the  hands 
of  Bonda,  Hufeland,  and  Alibert,  and  more  recently  by  Dr.  Wel- 
deck,  of  Berlin.  Dr.  Eberle  speaks  with  great  confidence  as  to  the 
value  of  this  remedy  from  the  experience  of  a  number  of  years  ;  lim- 
iting its  use  to  those  cases  in  which  there  is  absence  of  fever  and 
bronchial  inflammation,  and  where  the  disease  is  purely  of  a  spas- 
modic form. 

Hydro- cyanic  acid  has  of  late  been  much  used  in  the  treatment 
of  hoopingcough,  with  great  success  in  a  number  of  cases  ;  but,  like 
every  other  remedy  in  this  disease,  it  has  sometimes  failed  in  giving 
relief.  Dr.  Hamilton  Roe,  however,  observes,  "  that  the  cases  are 
so  very  numerous  in  which  this  medicine  succeeds, — especially  if  it 
be  given  at  the  commencement  of  the  disease, — and  so  very  few  in 
which  it  fails  of  speedily  producing  a  beneficial  effect  upon  the 
cough,  that  my  first  impression  on  hearing  that  a  child  who  has  been 
using  it  is  no  better  is,   that  the  acid  cannot  have  been  good." 


600  APPENDIX. 

(Treat,  on  the  Nat.  and  Treat,  of  Hoopingcough,  &c.,  London, 
1838.) 

A  mixture  of  belladonna,  ipecacuanha,  and  sulphur,  used  alter- 
nately with  hydro-cyanic  acid,  has  been  employed  by  Dr.  Kahleiss, 
(Hufeland's  Journal,  1829,  copied  in  the  Amer.  Jour.  Med.  Science, 
May,  1830,)  with  great  advantage  in  one  hundred  cases  of  pertussis, 
when  unattended  with  pulmonary  congestion.  The  prescriptions 
will  be  found  among  the  formulcs  at  the  end  of  the  appendix.  The 
proportion  of  the  articles  ought  to  be  increased  or  diminished  ac- 
cording to  the  age  of  the  child.  Sometimes  these  remedies  do  not 
snow  their  effects  in  four  or  five  days.  When  a  dilatation  of  the 
pupils  arises,  and  an  efflorescence  appears  on  the  skin,  the  treatment 
must  be  suspended  for  twenty-four  or  thirty-six  hours,  and  the  pro- 
portion of  belladonnae  diminished. 

The  use  of  antispasmodics  combined  with  expectorants  is  a  good 
course  of  treatment  to  adopt  when  there  remains  much  evidence  of 
bronchial  inflammation,  and  asafoetida  is  one  of  the  best  that  can  be 
used. 

In  protracted  cases,  attended  with  debility,  tonics  have  sometimes 
succeeded  ;  and  Peruvian  bark  has  been  used  for  a  long  time.  Sul- 
phate of  quinine  has  been  found  peculiarly  serviceable  by  Dr.  Dew- 
ees  ;  and  arsenic  was  employed  by  Dr.  Ferriar  as  a  tonic,  in  some 
cases  of  obstinate  hoopingcough,  with  advantage. 

Where  there  is  but  little  bronchial  inflammation,  a  change  of  air 
is  a  most  powerful  remedy,  and  in  protracted  cases  is  often  the  only 
one  which  will  arrest  the  disease. 

MENINGITIS HYDROCEPHALUS. 

Note  to  page  484. 

The  most  important  remedy  in  this  disease  is  early  bloodletting. 
It  is  a  disease  of  so  dangerous  a  character  that  it  is  of  the  highest 
importance  that  it  should  receive  prompt  attention  as  soon  as  its 
nature  is  perceived.  A  purgative  of  calomel  ought  to  follow  the 
bleeding,  both  for  the  purpose  of  removing  any  irritating  matters,  as 
well  as  by  its  influence  on  the  liver  and  entire  secretory  surface  of 
the  intestines  to  effect  a  powerful  revulsion  from  the  head.  Free 
leeching  from  behind  the  ears  ought  not  to  be  omitted.  The  state 
of  the  gums  must  also  be  examined,  and  cut  if  necessary. 

The  use  of  mercury  in  this  affection,  both  externally  and  inter- 
nally administered,  has  received  the  sanction  of  all  practical  writers. 


APPENDIX.  601 

Dr.  Mills,  in  a  paper  published  in  the  Transactions  of  tne  King's 
College  of  Physicians  in  Ireland,  recommends  its  use  in  combina-* 
tion  with  the  watery  extract  of  opium.  He  remarks,  "  the  good 
effects  of  a  combination  of  these  remedies  seem  to  depend  on  their 
power  of  equalizing  the  circulation,  increasing  the  secretions,  and 
exciting  the  action  of  the  cutaneous  vessels,  in  consequence  of  which 
the  congestion  of  the  blood  in  the  brain  or  in  any  other  part  is  re- 
moved." Occasional  revulsive  baths  to  the  lower  extremities,  while 
cold  is  appHed  to  the  head  by  means  of  a  bladder  partially  filled 
with  iced  water,  should  be  Used  while  the  head  continues  hot.  A 
blister  is  often  serviceable  on  the  neck  or  between  the  shoulders^ 
after  the  first  violent  symptoms  are  subdued. 

When  effusion  has  occurred,  little  or  no  benefit  can  arise  from  a 
perseverance  in  the  active  antiphlogistic  course.  Hydrogogue  ca-^ 
thartics  have  been  sometimes  successful  under  the  most  unpromising 
circumstances  in  children  advanced  beyond  the  period  of  infancy^ 
and  diuretics  might  be  advantageously  employed  after  effusion  has 
occurred.  A  case  came  to  the  writer's  knowledge  where  an  infant  of 
six  months  old,  after  having  every  symptom  of  effusion,  and  the  dis- 
ease, to  appearance,  fast  approaching  to  a  fatal  termination,  recover- 
ed after  a  spontaneous  discharge  of  a  large  quantity  of  urine. 

tiAfiiLiTir. 

Note  to  page  543. 

I  shall  conclude  these  notes  with  a  communication  which  I  re-* 
ceived  from  Professor  John  W.  Francis.  It  embraces  topics  hav-^ 
ing  a  close  relation  to  the  facts  and  doctrines  advanced  in  the  last 
section  of  Mons.  Billard's  treatise. 

New  York,  July  1st,  18.39- 
Dear  Sir, 

Agreeably  to  your  request,  I  have  hastily  put  together  some  re-- 
marks  on  that  section  of  Mons.  Billard's  work  which  relates  to  the 
viability  of  new-born  infants.  It  were  superfluous  to  offer  any  de- 
tailed observations  on  a  production  so  eminently  characterized  by 
close  investigation  and  reflections  as  the  entire  performance  of  M^ 
Billard  ;  and,  from  the  nature  of  your  investigations,  I  feel  justified 
in  restricting  the  present  note  to  this  last  portion  of  his  treatise^ 
which  more  especially  involves  disquisitions  on  juridical  medi- 
cine. 

76 


602  APPENDIX. 

In  the  elaborate  section  of  Mons.  B.  on  the  viability  of  new-born 
infants,  may  be  found  an  interesting  and  valuable  association  of  facts 
of  great  practical  importance,  and  which  recommend  themselves  to 
our  notice,  no  less  by  their  novelty  than  by  their  pathological  rela- 
tions. Many  of  the  circumstances  noticed  by  the  author,  while  they 
are  intimately  interwoven  with  the  science  of  forensic  medicine, 
must  be  familiar  to  all  who  have  observed  in  the  school  of  clinical 
experience  ;  but  never,  until  now,  has  so  large  a  group  of  hitherto 
isolated  facts  been  brought  to  bear  on  this  subject,  of  so  much  inter- 
est in  juridico-medical  investigation.  All  that  I  feel  authorized  to 
add  to  this  section  are  a  few  incidental  remarks,  having  a  tendency 
in  some  respects  to  corroborate  occasional  opinions  given  by  Mons. 
B.,  and  thus  augment  the  data  on  which  future  principles  on  some 
controverted  points  may  be  the  better  recognised. 

In  two  distinct  portions  of  this  elaborate  dissertation,  the  author 
has  enlarged,  with  philosophical  acumen,  on  the  alterations  of  color  of 
the  skin :  in  the  subsequent  part  he  has  dwelt  with  advantage  on  the 
most  striking  causes  of  cyanosis. 

We  must  ever  bear  in  mind  the  clinical  observation  of  Corvisart, 
that  cyanosis,  though  often  found  associated  with  an  open  state  of 
tVie  foramen  ovale,  may  yet  exist  without  this  imperfection  :  the  blue 
color  has  been  often  manifested  in  early  life,  while  no  communica- 
tion has  been  traced  between  the  opposite  sides  of  the  heart.  This 
patulous  condition  of  the  foramen  ovale,  though  actually  existing,  is 
sometimes  brought  to  evidence  itself  only  when  obstruction  of  the 
circulation  through  the  lungs  occurs  by  pulmonic  congestion  or  dis- 
ease. Crampton  tells  us  that  he  has  seen  several  cases  where  there 
was  a  free  opening  between  both  auricles  and  ventricles,  which  must 
have  subsisted  for  years,  and  yet  in  which  there  was  no  cyanosis. 
That  the  open  state  of  the  foramen  ovale  is  not  necessarily  a  cause 
of  cyanosis,  we  have  the  authority  of  M.  Ribes,  in  the  case  of  a  man 
of  sixty  years,  in  which  the  auricles  communicated  without  there  being 
any  change  in  the  color  of  the  skin.  In  a  recent  fatal  case  of  the 
puer  coeruleus,  occurring  in  a  subject  which  survived  but  about 
thirteen  days,  and  where  the  blue  color  was  periodically  intense,  the 
intermission  between  each  pulsation  was  very  repeatedly  seven  min- 
utes and  a  half,  and  on  some  occasions  eleven  or  twelve  minutes. 
The  double  relationship  between  the  state  of  the  lungs  and  that  of 
the  brain,  deserves  to  be  as  closely  scrutinized  as  the  condition  of 
the  heart  in  cyanosis.  We  have  all  recently  witnessed,  by  dissec- 
tion, during  the  prevalence  of  the  Asiatic  cholera  in  New  York,  the 


APPENDIX.  603 

influence  on  the  vascular  system  induced  by  obstructed  circulation 
in  the  lungs  and  through  the  heart.  A  like  remark  maybe  made 
concerning  the  disordered  phenomena  made  so  conspicuous  by  au- 
topsic  examinations  of  bodies  dead  by  the  drinking  of  cold  water 
during  the  extreme  heats  of  our  summer.  In  many  of  the  cases 
which  I  have  investigated,  the  lungs,  and  their  proximate  organ,  the 
heart,  have  betrayed  the  pathognomonic  signs  of  inordinate  thoracic 
fulness,  and  a  passive  dilatation  of  the  right  ventricle.  In  deaths 
by  lightning,  I  have  sometimes  traced,  by  dissection,  appearances 
of  a  similar  nature,  with  cerebral  fulness,  and  doubtless  accompa- 
nied with  exhaustion  of  all  nervous  energy.  So,  too,  by  the  dissec- 
tion of  the  dead  body  of  the  gross  inebriate,  these  local  disgorge- 
ments may  occasionally  have  been  seen,  while  upon  inquiry  it  is 
readily  ascertained  that  cyanosis  has  often  characterized  the  exter- 
nal surface  of  the  unfortunate  victim  previous  to  death.  All  these 
examples  may  be  cited,  to  demonstrate  a  cyanose  state  influencing 
a  stagnation  in  the  capillary  system.  In  short,  in  the  advanced 
stage  of  various  affections,  accompanied  with  a  disordered  circulation, 
we  may  often  become  the  observers  of  this  coerulean  discolora- 
tion. 

It  is  essential,  in  noticing  cases  of  preternatural  or  abnormal 
growth  of  the  tongue,  to  discriminate  between  congenital  enlarge- 
ments of  that  organ  and  glossitis,  embracing  the  numerous  causes 
which  induce  that  condition,  which  in  reality  ought  to  be  considered 
as  the  results  of  inflammatory  action.  Instances  of  this  character 
have  been  encountered  by  many  who  have  remarked  the  deplorable 
effects  of  mercury  on  some  individuals.  Dr.  Good's  Study  of  Medi- 
cine contains  some  valuable  records  of  cases  illustrative  of  the  re- 
marks of  our  author.     (See  edition  edited  by  Dr.  Doane.) 

The  observations  of  Mons.  B.  concerning  congenital  malforma- 
tions of  the  intestinal  canal,  are  in  conformity  with  the  experience 
of  all  conversant  with  autopsic  examinations.  An  instance  came 
within  my  own  inspection  several  years  ago,  of  the  smaller  intes- 
tines, so  called,  being  in  reality  the  larger,  while  nearly  the  whole 
tract  of  colon  and  rectum  was  so  diminished  in  its  caliber  as  scarcely 
to  admit  the  passage  of  a  crow's  quill.  The  child  lived  until  the 
fourth  day  after  its  birth,  and  no  suspicion  was  entertained  of  any 
abnormal  state  until  some  forty  hours  of  its  life  had  passed,  and  the 
derangement  of  its  excretory  functions  led  to  a  closer  scrutiny  of  its 
physical  condition.  Dissection  made  palpable  the  fatal  peculiarity 
of  structure.     A  very  striking  variety  of  intestinal  structure  is  re- 


604 


appf:ndix. 


corded  in  the  American  Medical  and  Philosophical  Register  of  New 
York,  which  deserves  to  be  adverted  to  in  these  addenda,  not  only 
on  account  of  its  extreme  rarity,  but  because  of  its  signal  influence 
as  an  efficient  agent  in  determining  the  fatality  of  various  affections 
of  the  bowels.  This  case  of  peculiarity  of  formation  is  denomina- 
ted a  diverticulum  from  the  ileum  attached  to  the  umbilicus.  The 
patient  died  from  obstruction  and  enteric  inflammation.  The  pre- 
ternatural formation  was  about  three  inches  in  length,  and  so  fiirmly 
attached  to  the  umbilicus  as  to  leave  no  doubt  of  its  having  been  a 
congenital  product ;  and  yet  this  patient  had  arrived  at  the  age  of 
thirty-five  years.  The  details  of  this  instructive  example  of  intesti- 
nal malformation  I  have  published  at  length  in  the  work  just  refer- 
red to  ;  volume  1st,  1810. 

The  remarks  of  Mons.  B.  on  the  disorganization  of  the  mucipa- 
rous follicles  of  the  intestines,  are  of  unquestionable  importance  in 
a  practical  and  in  a  medico-juridical  point  of  view.  The  cause  which 
he  seems  to  have  assigned  as  the  origin  of  the  cholera  infantum  in 
America  is  too  restricted ;  though  there  is  a  sound  and  important 
inference  to  be  drawn  from  his  reflections  on  the  nature  and  charac- 
ter of  the  different  species  of  alvine  discharges  depending  on  the 
diseased  condition  of  the  internal  lining  of  the  intestinal  tube.  The 
white  or  pultaceous  softening  of  the  mucous  membrane  of  the  intes-^ 
tine  is  undoubtedly  conspicuous  among  the  causes  of  this  aff*ection  : 
and  as  it  is  a  disorder  often  occurring  among  the  inhabitants  of  warm 
cHmates,  we  may  be  led  to  infer  that  disorganization  in  the  functions 
of  the  liver  is  at  times  to  be  enumerated  among  the  sources  in  its 
production.  Dr.  Baillie,  in  the  Medical  Transactions  of  the  Col-* 
lege  of  Physicians  of  London,  vol.  5,  has  a  paper  on  a  kindred  af- 
fection, which  he  has  termed  a  peculiar  species  of  purging,  and 
which  he  says  is  hardly  ever  radically  removed.  Persons  who  have 
resided  for  a  considerable  time  in  a  warm  climate,  he  observes,  and 
those  who  have  suffered  from  affections  of  the  liver,  are  more  liable 
to  it :  but  it  occasionally  takes  place  in  those  who  have  never  been 
out  of  Great  Britain,  and  who  have  never  suflfered  from  any  disease 
of  the  liver.  It  occurs  more  frequently  in  men  than  in  women  ;  but 
this  he  thinks  most  probably  depends  in  a  great  measure  upon  a 
larger  proportion  of  men  going  to  warm  climates  than  of  women. 

This  affection  is  sometimes  found  to  afflict  individuals  who  arrive 
in  New  York  from  our  Southern  states.  In  all  the  cases  which  I 
have  seen  they  were  male  subjects  ;  and  of  eight  instances  of  the 
complaint,  two  were  evidently  blended  with  hepatic  disturbance. 


APPENDIX.  605 

It  occasions  within  a  short  period  extreme  emaciation,  and  a  state  of 
the  surface  not  unlike  that  induced  by  diabetes.  The  mercurial 
treatment  is  unavailable.  Strychnine  I  have  thought  in  some  in- 
stances a  valuable  adjuvant  to  the  most  appropriate  means  of  relief 
pointed  out ;  but  for  the  most  part  this  chronic  disorganization  of 
the  viscera  is  found  to  baffle  the  soundest  principles  of  the  curative 
art. 

The  facts  of  the  early  hepatization  of  the  lungs,  remarked  by  our 
author,  have  occasionally  been  observed  by  American  pathologists. 
We  may  also  add  that  the  phenomena  of  partial  respiration,  as  re- 
corded by  Mons.  B.,  by  which  the  infant  may  seem  to  be  endued 
with  life  and  yet  shortly  expire  from  the  want  of  a  free  and  permea- 
ble respiration,  have  been  witnessed  by  every  physician  extensively 
engaged  in  obstetrical  practice.  That  instances  of  asphyxia  in  new- 
born infants  are  sometimes  the  result  of  the  action  of  ergot  or  spur- 
red rye,  administered  during  labor,  cannot  admit  of  doubt.  Several 
of  my  medical  friends  have  observed  cases  of  asphyxia  arising  from 
this  origin  ;  and  I  feel  persuaded  that  the  annual  list  of  stillborn 
infants,  published  by  our  constituted  authorities  in  the  bills  of  mor- 
tality, is  greatly  increased  in  numbers  by  the  use  of  this  potent 
agent.  Indeed,  I  deem  it  expedient  that  in  all  cases  of  stillborn 
children,  inquiry  should  be  made  whether  ergot  had  been  adminis- 
tered during  the  parturition. 

There  is  much  observation  and  close  reflection  in  the  second  part 
of  our  author's  paper,  and  his  medico-legal  inductions  are  to  be 
ranked  among  the  best  grounded  in  the  science  of  physiology  and 
pathology.  The  many  volumes  which  have  been  written  on  the 
docimasia  pulmonum  since  the  celebrated  essay  by  Dr.  William 
Hunter,  render  it  unnecessary  to  enlarge  at  an  extent  on  this  per- 
plexing subject.  The  test  of  Dr.  Hunter  concerning  the  floating  of 
the  lungs  of  the  child  who  has  respired,  and  the  vast  inferences  which 
have  hence  been  deduced  from  these  circumstances,  are  not  at  the 
present  day  considered  so  conclusive  as  they  were  estimated  at  an 
earlier  period  in  medico-legal  studies.  Though  Swammerdam  and 
Haller,  as  well  as  Hunter  and  other  high  authorities,  aflirmed  that  a 
single  respiration  would  cause  the  lungs  to  float,  yet  the  obstetrical 
practitioner  is  aware  that  children  occasionally  do  not  breathe  until 
they  are  born  for  some  time ;  that  respiration  itself  does  not  uni- 
formly dilate  the  lungs,  and  that  they  are  in  some  instances  so  feebly 
or  partially  dilated  by  imperfect  breathing,  as  nevertheless  to  sink 
in  w^ter.     Nor  need  we  marvel  at  these  phenomena,  the  fact  being 


606  APPENDIX. 

well  recognised,  that  an  ordinary  inspiration  dilates,  but  in  part, 
the  entire  pulmonary  lobules,  even  in  the  normal  condition  of 
the  organs.  These,  and  many  other  facts  of  an  indubitable  nature, 
have  rendered  the  hydrostatic  test  upon  which  so  much  reli- 
ance was  once  placed  inconclusive.  I  lately  witnessed  a  case  of 
premature  deUvery,  at  the  period  of  seven  months  gestation,  in 
which  the  child  manifested  feeble  respiration  somewhat  over  two 
hours,  when  life  no  longer  being  apparent,  the  lungs  were  subjected 
to  the  hydrostatic  test  of  Hunter  ;  and,  though  the  lungs  were  mi- 
nutely divided  into  small  portions,  yet  each  portion  sank  in  pure 
water :  this  instance,  indeed,  occurred  to  the  lungs  of  a  seventh 
month  child,  but  I  might  here  record  the  particulars  of  several  ex- 
amples occurring  with  the  lungs  of  children  born  at  the  full  time,  and 
with  a  like  result.  Schenkius,  and  also  Bernt  and  others,  have  ob- 
served the  same  result  of  the  inability  of  the  lungs  to  float,  though  cut 
into  pieces,  even  when  taken  from  the  infant  born  at  the  mature  pe- 
riod, and  who  had  lived  one,  or  even  two  days. 

I  purposely  avoid  detailing  the  several  states  of  diseased  or  con- 
gested lungs  in  infants,  which  might  entirely  defeat  the  validity  of 
the  test  of  Hunter  ;  nor  need  I  dwell  upon  the  practical  inference 
which  may  be  deduced  from  the  occurrence  that  the  child  will  occa- 
sionally enjoy  a  fair  respiration  upon  the  protrusion  of  the  head, 
while  the  shoulders  are  locked  in  ;  and  in  such  case  be  wedged  be- 
yond the  possibility  of  the  natural  efforts  effecting  its  complete  birth. 
Moreover,  Professor  Osiander,  on  the  respiration  of  the  foetus,  has 
given  us  important  facts  touching  the  vagitus,  respiration,  and  vital- 
ity of  the  human  foetus  during  and  immediately  after  parturition ; 
from  which  it  may  be  safely  inferred  that  in  twelve  cases  at  least, 
under  his  own  observation,  the  child  breathed  and  cried  after  the 
head  was  born,  while  its  entire  and  safe  birth  was  nevertheless  sub- 
jected to  various  contingencies. 

Next  to  the  hydrostatic  test  of  Hunter,  the  nova  docimasia  of 
Ploucquet  deserves  a  passing  remark  :  and  a  rigid  inference  from 
facts  compels  us  to  say  that  the  observations  which  Jaeger  has  made 
as  to  the  relative  proportions  of  the  lungs  and  the  body  of  the  child, 
whether  male  or  female,  and  the  difference  in  the  nutrient  or  vascular 
capabilities  of  difl'erent  individuals  in  thoracic  development,  all  pre- 
sent conclusive  reasons  why  this  test,  once  thought  so  beautiful  and 
so  legitimate,  is  still  not  safely  to  be  admitted  as  furnishing  correct 
conclusions  on  so  vexed  a  subject  as  infanticide.  The  most  conspic- 
uous writers  on  medical  jurisprudence  abroad,  as  well  as  some  of 


APPENDIX.  607 

our  own  country,  have  given  us  the  results  of  their  investigations  on 
this  test  in  so  convincing  a  manner,  that  I  shall  terminate  these  casu- 
al reflections  on  the  docimasia  pulmonum  with  a  quotation  from  a 
note  published  in  the  third  edition  of  Denman's  Midwifery,  in  which 
it  will  be  seen  that  the  inferences  of  Ploucquet  are  far  from  satisfac 
tory,  though  I  estimate  this  test  more  favorably  than  some  others 
who  have  given  us  their  researches  on  this  notable  topic.  Since  the 
publication  of  this  edition  of  Denman,  I  have  had  many  opportu- 
nities of  further  practical  investigation,  and  the  details  of  thirty  sub- 
sequent cases  might  be  added  ;  all,  however,  in  no  wise  impairing 
the  positions  set  forth  in  the  citation  which  I  here  make. 

"The  hydrostatic  test  of  the  lungs,  though  so  ably  maintained  by 
Dr.  Hunter,  has  not,  I  think,  advanced  in  estimation  by  the  latest 
facts  concerning  the  docimasia  pulmonum :  while  I  am  disposed  to 
yield  my  conviction  that  the  test  of  Ploucquet,  founded  on  the  abso- 
lute weight  of  the  lungs,  deserves  much  higher  consideration  than  it 
has  usually  received.  I  am  led  to  this  opinion  from  the  many  op- 
portunities of  actual  observation  on  the  subject  which  have  occurred 
to  me  during  a  period  of  ten  years,  chiefly  as  medical  witness  and 
adviser  in  the  criminal  courts  of  the  city  of  New  York.  The  posi- 
tive evidence  which  seems  to  be  afforded  by  the  fact  that  the  infant 
had  breathed  and  lived  after  its  birth,  because  of  the  lungs  being  ca- 
pable of  floating  in  water,  and  the  reverse  of  the  case,  that  their 
incapacity  to  float  in  water  is  proof  that  the  infant  was  born  dead, 
are  invalidated  by  numerous  experiments  of  several  pathological  ob- 
servers ;  and  although  the  lungs  afford  proof  of  respiration,  it  is  na 
evidence  that  the  infant  was  born  alive.  Hunter  yields  this  circum- 
stance, and  the  occurrence  has  repeatedly  fallen  under  the  notice  of 
accoucheurs.  We  must  ever  bear  in  recollection  that  respiration  is 
a  gradual  process  ;  that  its  first  efforts  are  imperfect,  and  that  there 
IS  a  remarkable  diflference  in  the  time  of  its  development  in  different 
infants,  depending  upon  the  greater  or  less  degree  of  vigor  with 
which  the  infant  is  endowed.  Schmitt  states,  that  he  has  seen  the 
whole  thoracic  cavity  occupied  in  infants  who  had  not  respired  ; 
while  in  the  infants  who  had  respired  for  thirty-six  hours,  the  lungs 
were  so  little  distended  that  one  could  scarcely  find  them,  though 
they  were  filled  with  air.  At  the  trial  of  a  young  woman  for  child 
murder,  at  the  Warwick  assizes,  England,  which  took  place  some 
few  years  ago,  this  defence,  which  proved  successful,  rested  upon 
the  principle  that  the  human  foetus  may  respire  as  soon  as  the  head 
is  expelled  in  delivery.     The  medical  witness  expressed  himself 


608  APPENDIX. 

most  anxious  that  *  the  minds  of  the  jury  should  be  duly  impressed 
with  the  important  truth  that  a  child  may  breathe  and  even  cry  audi- 
bly as  soon  as  the  head  is  delivered,  and  yet  subsequently  perish  be- 
fore the  whole  body  is  expelled.'     See  London  Med.  Repos.,  vol.  xi. 

"  The  emphysematous  state  of  the  lungs  produced  in  cases  where 
the  child  has  been  suffocated  or  strangled  after  birth,  deserves  to  be 
specially  noticed,  as  well  as  the  peculiar  appearances  of  the  lungs, 
which  depend  upon  air  generated  by  decomposition.  But  the  tardi- 
ness of  the  lungs  to  run  into  putrefaction,  is  a  fact  familiar  to  every 
pathologist  and  every  student  in  a  dissecting  room.  Ballard  exam- 
ined a  child  in  a  state  of  such  putrefaction  that  its  sex  could  no  be 
discriminated,  and  the  muscles  of  its  face  were  reduced  to  a  pulp,  yet 
did  its  lungs  sink.  I  have  on  several  occasions  witnessed  an  equal 
degree  of  decomposition  in  infant  bodies  whose  lungs  bore  not  the 
least  evidence  of  putrescency  by  the  hydrostatic  test.  In  further 
corroboration,  the  following  quotation  is  taken  from  Camper  :  '  In 
order  to  ascertain  to  what  degree  putrefaction  would  advance  in  an 
infant  before  its  lungs  would  float  in  water,  I  made  different  experi- 
ments at  Amsterdam  on  this  subject ;  and  I  have  found  that  in  those 
who  had  died  before  birth  the  head  may  be  so  far  decomposed  by 
putrefaction  that  the  slightest  force  was  sufficient  to  detach  the  bones 
from  each  other,  as  well  as  those  of  the  arms  and  legs,  before  the 
lungs,  which  now  began  to  participate  in  the  putrefaction,  would 
float  in  water.' 

"  Rare  as  cases  of  diseased  lungs  are  in  infants  newly  born,  the 
instances  are  nevertheless  sufficient  to  cause  us  to  conduct  investi- 
gations of  this  nature  with  the  greatest  circumspection.  By  inflam- 
mation we  know  the  lungs  acquire  additional  specific  gravity,  and 
hence  might  sink.  In  the  instance  of  a  child  who  maintained  a  sick- 
ly existence  and  died  on  the  morning  of  the  third  day  after  its  birth, 
I  witnessed  the  sinking  of  the  lungs  from  a  morbid  congestion,  re- 
sembling hepatization.  Other  conditions  of  the  lungs  of  infants 
have  been  seen,  as  a  tuberculous  state.  Hence  the  necessity,  when  we 
employ  the  hydrostatic  test,  of  dividing  the  lungs  and  experimenting 
with  them  in  portions.  But  I  am  not  now  discussing  the  merits  of 
the  hydrostatic  test ; — my  present  intention  is  to  record  some  ad- 
ditional testimony  in  behalf  of  the  knowledge  derived  from  the  nova 
docimasia  of  Ploucquet. 

"  It  appears  that  the  changes  effected  by  respiration  in  the  lungs 
have  shown  that  these  organs  undergo  a  great  alteration  in  their 
specific  gravity  by  this  function :  respiration  is  accompanied  with  an 


APPENDIX.  609 

increase  of  the  flow  of  blood  to  the  lungs  ;  hence  the  pulmonary  ar- 
teries become  dilated,  and  their  ramifications,  thus  surcliarged,  aug- 
ment the  volume  of  the  lungs.  This  change  may  be  deemed  perma- 
nent ;  by  the  increased  capacity  of  the  vessels,  a  larger  quantity  of 
blood  remains  after  death,  and  the  real  weight  of  the  lungs  is  increas- 
ed. This  pathological  truth  was  noticed  by  Ploucquet  as  early  as 
the  year  1777,  and  is  given  in  his  Commentarius  Medicus,  printed 
in  1786.  It  would  appear,  from  the  observations  of  Ploucquet,  that 
the  weight  of  the  lungs  of  a  full  grown  foetus  which  had  never  re- 
spired, is,  to  that  of  its  whole  body,  as  one  to  seventy ;  while  in 
new-born  infants,  after  respiration  had  been  established,  it  was  in- 
creased as  two  to  seventy,  or  as  one  to  thirty-jive.  The  experiments, 
however,  on  which  these  deductions  are  founded,  are  but  few  in 
number :  in  one  case,  where  the  new-born  child  had  not  respired, 
Ploucquet  found  the  lungs  as  1  to  67.  In  another  case  of  a  mature 
foetus,  which  never  breathed,  the  lungs,  in  comparison  of  the  body, 
were  as  1  to  70  ;  and  in  another,  where  the  child  was  not  quite  per- 
fect, but  had  breathed,  he  found  the  lungs  as  2  to  70.  From  these 
few  facts,  he  says :  *  Videmus  exinde,  pondus  pulmonum  ab  acce- 
dente  per  respirationem  sanguine,  et  post  mortem  iis  adhuc  inhae- 
rente  duplicari  adeoque,  in  casibus,  dubiis  banc  normam  esse,  ope 
cujus  de  facta,  vel  non  facta  respiratione  judicare  possimus.'  (Com- 
ment. Med.  in  Proces.  Crim.,  p.  280.) 

"Dr.  Hutchinson  has  oflfered  several  arguments  and  facts  which 
tend  to  disparage  the  importance  of  Ploucquet's  test ;  and  Haart- 
mann  has  stated  that  he  has  not  found  the  relation  of  the  weight  of  the 
body  to  that  of  the  lungs  even  nearly  similar  to  that  mentioned  by 
Ploucquet.  Haartmann  gives  about  48  to  1  as  the  proportion  after 
respiration  has  been  effected,  and  about  59  to  1  as  that  existing  be- 
fore respiration.  Struve  states  that  he  has  found  no  constant  rela- 
tion between  the  weight  of  the  lungs  and  the  body  under  these 
circumstances  ;  and  to  these  authorities  we  may  add  Schmitt.  That 
there  is  great  diversity  in  the  results  of  experiments  on  this  subject, 
will  be  readily  admitted  ;  and  no  stronger  proof  of  it  need  be  given 
than  that  drawn  from  the  examinations  of  Lecieux,  of  the  Hospice 
de  la  Maternite,  at  Paris.  I  shall  here  give  the  results  of  a  series  of 
experiments  undertaken,  as  occasions  presented  to  me,  for  the  pur- 
pose of  ascertaining  in  the  most  satisfactory  manner  the  truth. 

"In  case  1,  where  it  was  sufficiently  evident  that  the  child  had  not 
been  born  alive,  the  proportion  between  the  weight  of  the  lungs  and 
the  whole  body  was  as  1  to  47.     In  case  2,  of  a  foetus  at  full  five 

77 


610  APPENDIX. 

months,  the  proportion  between  the  lungs  and  the  whole  body  was 
as  1  to  29.  In  case  3,  of  a  foetus  nearly  six  months,  the  proportion 
was  as  1  to  39.  In  case  4,  where  the  child  was  stillborn,  (weight 
five  pounds  eleven  ounces,)  the  proportion  was  as  1  to  52.  In  case 
5,  of  a  foetus,  weight  two  pounds  five  ounces,  the  proportion  was  as  1 
to  40.  In  case  6,  of  an  abortion  at  the  latter  part  of  the  sixth 
month's  pregnancy,  the  proportion  was  as  1  to  39  5-7.  In  case  7, 
of  an  abortion  at  the  end  of  five  months'  gestation,  the  proportion 
was  as  1  to  46.  In  case  8,  of  an  early  abortion,  time  accidentally 
omitted,  the  proportion  was  as  1  to  41.  In  case  9,  an  early  abortion, 
the  proportion  between  the  lungs  and  the  body  was  as  1  to  27.  In 
case  10,  of  a  child  which  had  for  a  few  moments  respired,  the  pro- 
portion was  as  1  to  36.  In  case  11,  of  premature  delivery  at  about 
the  eighth  month,  and  where  the  respiration  had  been  established, 
the  proportion  was  as  1  to  32.  In  case  12,  of  premature  delivery  at 
seven  months,  and  in  which  the  child  breathed  feebly  for  two  hours, 
the  relative  proportion  of  the  weight  of  the  lungs  to  that  of  the  entire 
body  was  as  1  to  43.  In  case  13,  an  abortion  at  seven  and  a  half 
months,  the  child  possessing  imperfect  respiration  some  forty  min- 
utes, the  proportion  was  as  1  to  43.  In  case  14,  in  which  the  child 
was  stillborn  at  the  full  time,  the  proportion  was  as  1  to  66.  In 
case  15,  an  instance  of  birth  at  eight  months  and  a  half,  the  child  ef- 
fecting some  few  imperfect  respirations,  the  lungs  were  to  the  body 
as  1  to  40. 

"  From  these  results,  I  am  led  to  give  an  opinion  that  the  test  of 
Ploucquet  ought  to  be  better  known  in  our  criminal  courts,  and  that 
our  jurists  might  profitably  avail  themselves  of  its  principles.  It 
will  materially  aid  in  the  deficiences  of  the  hydrostatic  test  of  Hun- 
ter. But  to  render  the  test  less  uncertain,  we  ought  to  know  more 
precisely  the  relative  proportion  between  the  weight  of  the  lungs 
and  the  body  of  the  foetus  at  diflferent  periods  of  gestation.  The 
celebrated  Orfila  instituted  a  series  of  experiments  for  the  purpose 
of  calculating  the  relative  weight  of  the  lungs,  not  only  as  respects 
the  entire  body,  but  as  respects  the  heart  ;  and  he  frankly  acknowl- 
edged the  impossibility  of  drawing  therefrom  any  positive  inference. 
The  proposed  modification  of  Ploucquet's  test,  by  Daniel,  and  yet 
more  recently  (1821)  by  Brent,  are  less  available  for  practical  pur- 
poses than  the  test  of  Ploucquet." 

There  is  another  point  of  inquiry  which  I  believe  has  scarcely 
been  adverted  to  by  Mons.  Billard.  I  allude  to  the  particular  period 
of  gestation  at  which  the  viability  of  the  foetus,  or  its  capability  of 


APPENDIX.  611 

supporting  extra-uterine  life,  may  be  presumed.  I  recollect  the  case 
recorded  by  Dr.  Rodman  in  the  Edinburgh  Medical  and  Surgical 
Journal,  of  his  patient  having  been  delivered  at  the  end  of  the  nine- 
teenth week  of  pregnancy :  to  this  case  I  was  originally  referred  by 
my  late  colleague  in  the  University,  Professor  Wright  Post,  as  among 
the  best  attested  instances  recorded  of  extra-uterine  life  at  so  early  a 
period ;  and  such  I  believe  it  still  stands  ;  though  some  controversy 
has  arisen  as  to  the  correctness  of  Dr.  Rodman's  reasoning  ;  the 
feebleness  and  size  of  the  child  being  uncertain  data  by  which  to  ar- 
rive at  a  positive  conclusion  :  and  further,  too,  as  Mr.  Baker  has 
subsequently  published  the  case  of  a  child  born  at  the  full  period  ot 
utero-gestation,  which  corresponded  in  size  very  closely  with  the 
one  made  known  by  Dr.  Rodman.  I  am  the  more  inclined  to  confide 
in  the  accuracy  of  Dr.  Rodman's  statement  from  having  seen  a  re- 
markable instance  of  a  similar  kind.  In  October  last,  1838,  I  was 
requested  to  meet  in  consultation  in  a  case  of  retained  placenta ; 
the  patient,  from  fatiguing  exertions,  had  been  prematurely  seized 
with  labor  pains,  and,  after  unavailing  measures  of  prevention,  was 
delivered,  in  the  twentieth  week  of  gestation,  of  a  male  foetus,  which 
by  distinct  respirations  sustained  life  one  hour.  After  death  it  was 
found  to  weigh  one  pound  six  drachms  :  its  length  was  ten  inches, 
and  it  was  well  formed.  Too  many  circumstances  conspired  to 
render  the  age  of  the  foetus  doubtful ;  it  was  the  product  of  a  first 
conception,  and  the  parties  were  beyond  suspicion. 

My  friend  Dr.  Wm.  Barrow  favored  me  several  years  ago  with  a 
foetus  which  was  spontaneously  protruded  between  the  seventh  and 
eighth  month  of  gestation,  the  weight  of  which  was  little  more  than 
five  ounces.  The  cause  of  so  extraordinarily  immature  and  limited 
growth  at  this  advanced  period,  was  ascertained  to  be  a  disordered 
condition  of  the  cord,  which  impaired  the  foetal  circulation.  I  give 
you  this  case  because  it  is  calculated  to  lead  us,  in  all  inquiries  of 
this  nature,  where  we  might  conclude  too  hastily  as  to  the  age  of  the 
foetus  by  its  bulk  alone,  to  advert  to  the  condition  of  the  cord ;  inas- 
much as  an  abnormal  formation  of  this  connecting  link  between  the 
mother  and  child,  as  well  as  the  sound  or  disordered  development  of 
the  placenta,  must  exercise  a  controlling  influence  on  the  vascular 
energies,  and  more  or  less  circumscribe  the  growth  and  dimensions 
of  the  foetus.  There  is  much  that  might  be  said  on  this  subject, 
and  in  Cruvelhier  we  find  a  number  of  observations  illustrative  of 
the  various  causes  which  disturb  that  functional  reciprocity  which 
in  the  pregnant  state  is  indispensable  to  the  sound  and  full  forma- 


^12  APPENDIX. 

tion  of  the  uterine  product.  It  is  worthy  of  remark  that  in  the  case 
published  by  Dr.  Rodman  no  notice  is  taken  of  any  peculiarity  in 
the  cord,  and  in  that  which  I  have  given  its  healthy  structure  was 
obvious. 

I  will  add  another  case  illustrative  of  the  early  period  at  which 
extra-uterine  life  may  occur,  and  in  which  the  viability  has  secured 

the  subject  now  some  seven  years.     Mrs.  B had  been  delivered, 

after  protracted  sufferings,  of  a  dead  male  child,  at  the  ordinary 
term  of  a  first  pregnancy.  Twenty  months  after,  the  inconve- 
niences of  a  second  pregnancy  were  so  great  that  she  was  on  sev- 
eral occasions  threatened  with  abortion.  Neglecting  the  precau- 
tions recommended  her,  she  had,  during  the  prevalence  of  the 
Asiatic  cholera  in  1832,  indulged  in  eating  freely  of  Indian  corn, 
which  created  much  annoyance  in  the  stomach  and  bowels,  and 
in  the  opinion  of  several  of  her  friends  it  was  thought  that  this 
indulgence  was  the  exciting  cause  of  her  premature  labor.  By  one 
powerful  effort  the  entire  ovum  was  expelled.  Arriving  at  this 
crisis,  I  had  the  whole  immersed  in  a  vessel  of  tepid  water,  and 
having  rendered  the  mother  more  secure  and  confortable  by  a  band- 
age, forthwith  ruptured  the  rriembranes,  when  to  my  surprise  I  per- 
ceived a  foetus,  apparently  of  some  five  months  and  upwards  of 
growth.  The  cord  was  divided,  and  more  than  usual  care  taken 
with  the  child  ;  a  fillet  or  ribbon  was  applied  round  its  head,  which 
seemed  unusually  large,  and  the  body  wrapped  in  cotton.  By  unremit 
ting  attention  on  the  part  of  a  competent  nurse,  the  fondest  wishes  of 
the  parents  were  ultimately  realized,  and  the  daughter,  in  the  enjoy- 
ment of  excellent  health,  has,  at  the  present  writing,  completed  her 
seventh  year.  Subsequent  inquiry  with  the  parents  concerned  made 
the  age  of  this  premature  offspring  at  birth  a  foetus  of  the  twenty- 
third  week  of  pregnancy. 

But  I  am  admonished  to  terminate  this  desultory  epistle,  and  con- 
clude with  assuring  you  that  the  interests  of  medical  knowledge  will 
be  greatly  advanced  by  your  English  translation  of  Mons.  Billard's 
work. 

JOHN  W.  FRANCIS. 

Dr.  Stewart. 


SELECT  FORMULJi;  FOR  INFANTS. 


5:  Aquae  destillatae,  §j. 
Mucil.  gum.  acac,  ^ss. 
Syrupi  sirnplicis,  gss. 
Tincturae  opii,  guttam. 
Dose,  a  teaspoonful,  repeated  every  half 
hour,  till  rest  be  procured  ;   but  after  the 
first  month,  double  that  quantity  will  be 
required.     After  the  third  month,  half  a 
drop  of  laudanum   may  be   given  for  a 
dose,  one  drop  at  six  months,  and  two  af- 
ter the  first  year. 

Evanson  and  Maunsell, 

^  Cretae,  ^ss. 

Atim.  oxy-sulph.,  gr.  iv. 
Ext.  hyoscyami,  gr.  xiij. 
Sacchar.  alb.,  3ij. 
A  teaspoonful  every  two  hours  in  infan- 
tile asthma.  Urban. 

"fy  Aq.  foeniculi,  5iv. 
Vini  antimonii,  3j. 
Ext.  hyoscyam.,  gr.  iij. 
Syrup,  althaeas,  §jss, 
A  teaspoonful  every  two  hours  to  an  in- 
fant from  six  to  twelve  months,  as  a  cough- 
mixture.  Vogt. 

Ijl;  Ext.  hyoscyam ,  gr.  x. 
Vini  antim.,  3ij, 
Eight  drops  four  times  a  day  to  an  in- 
fant a  year  old,  in  hoopingcough. 

Hufeland. 

I^i  Ext.  belladonnse,  gr.  j. 
Aq.  destilL,  §j. 
To  infants,  five  drops  four  times  a  day, 
in  hoopingcough.  Wcndt. 


I^  Pulv.  rad.  belladon.,  gr.  iv. 
"      Doveri,  gr.  x. 
Lac.  sulphuris,  3iv. 
Sacchar.  alb.,  5ij. 
M.    Divid.  in  chart.,  xx. 
In  hoopingcough,  one  of  these  powders 
every  three  hours  for  a  child  of  two  years ; 
one  fourth  for  a  child  of  eight  or  nine 
months.    Between  each  dose  a  teaspoonful 
of  the  following  mixture  to  a  child  two 
years  old ;  to  be  diminished  according  to 
the  age  of  the  child  : 

I^  Aq.  chamomile,  §j 
Syrup,  simp.,  3ij. 
Acid.  Prussic.  Vauqul.,  gt.  xij. 
Kahleiss^ 

I^  Magnes.  alb.  ust.,  3j. 
Tinct.  foetid.,  gt.  Ix. 

"       opii,  gt.  XX. 
AqusB  font.,  ij. 

M.  Twenty  drops  to  a  child  fi-om  two 
weeks  to  one  month,  in  colic  ;  if  not  re- 
lieved in  half  an  hour,  two  drops  more. 
Increasing  the  dose  as  the  child  advances 
in  age.  Dewccs. 

I]t  Ext.  conii  maculat.,  3j. 
Tinct.  camp,  opiat.,  iss. 
Syrup,  tolu.,  §ss. 
Aquae  rosar.,  §iv. 
M.  Dose,  half  a  teaspoonful  to  a  child 
one  year  old,  in  pertussis. 

CARMINATIVES   AND   ANTAaDS. 

R  Magn,  carb.,  3ss. 
Tinct,  rhei,  3j. 
Aq.  month.,  3vj. 


614 


APPENDIX. 


Syrup  alth.,  ij. 

M.  Sit  mistura. 

S.  A  teaspoonful  every  hour  for  an  in- 
fant of  six  months,  troubled  with  acidity 
of  the  stomach.  Vogt. 

^  Magnesise,  gr.  viij. 
Sem.  anisi  cont. 
Sem.  foenic.  cont.,  aa  gr.  ij. 
Croci,  gr.  j. 
Sacchar.  alb.,  gr.  vij. 
Contunde  bene  simul  ut  sit  pulvis. 
In  tormina  of  infants,  one  half  to  be  ta- 
ken at  once,  and  the  remainder  in  half  an 
hour.  Copland. 

I^t  Sodae  sesquiearb.,  gr.  iss. 
Pulv.  rhei,  gr.  iij. 
Pulv.  valerian.,  gr.  j. 
S.  A  powder  thrice  a  day  for  infants 
subject  to  flatulent  colic. 

^  Magn.  carb.,  3j. 
Pulv.  rhei,  3ss. 
Saponis,  3j. 
Ft.  pulvis, 

S.  Ten  grains  thrice  a  day  for  constipa- 
tion, with  acidity.  Berends. 

13^  Magn.  carb.,  3ij. 

Pulv,  rhei,  3j. 

Aq.  fcEniculi,  §iss. 

Syrup,  rhei,  ^ss. 
M.  Sit  mistura. 
Dose,  a  teaspoonful.  Berends. 

I^  Aquae  foeniculi,  ^vij. 
Potassae  bicarb.,  3ij. 
Syrupi,  §j, 
M,  A  dessert  spoonful  occasionally, 

fjl;  Potassae  bicarb.,  5ss. 
Aq.  destil.,  §iss, 
Solve. 
S.  Ten  to  forty  drops  daily.     In  infan- 
tile convulsions.  Hamilton. 

Ijt  Potassae  bicarb,,  3ij. 

Succ.  limon,  q,  s,  ad  saturationem. 


Infus.  rhei,  §iss. 
Mannae,  §ss. 

One  or  two  teaspoonfuls  to  infants  in 
gastric  disorders. 


R  Hyd,  c.  creta,  5ij. 

Sodae  carb.  excicat.,  3iv. 

M.  From  six  to  twelve  grs.  for  an  in- 
Copland. 


fant, 


ANTISPASMODICS, 

I^  Cretae,  gr.  iij. 
Moschi,  gr.  ss. 
Croci,  gr,  i. 

Ft.  pulv.  dent.  tal.  dos,,  No,  iv, 
S,  One  every  hour  for  an  infant. 

Frankel. 

R  Moschi,  3j, 
Pulv.  acaciae,  3ij, 
Tere  cum  aq.  cinnam,,  |j. 
Syrup,  althaeae,  giij. 

M,  Sit  mistura. 

S,  A  spoonful  every  hour. 

I^  Moschi,  gr.  vj. 

Ammon.  sesquiearb,,  gr.  iv. 
Sacchari  albi,  3iij, 
Misce  terendo  et  adde, 
Aq.  for.  sambuci,  iijss. 
M.  Sit  mistura. 

S.  A  teaspoonful  every  hour  in  infan- 
tile fits.  Wendt. 

I^  Asafoetidae,  gr.  vj — viij. 
Infus.  anthemid.,  §j, 
Acaciae,  q.  s. 

M.  f  enema. 

I^  Lactis  tepefact.,  ij. 
Aq.  menth.  pip.,  §ss. 
Tinct.  asafoetid.,  3j. 

M,  Injicienda  pro  enemata.    In  con- 
vulsions. 


EXPECTORANTS  AND  DEMULCENTS. 

R  Pulv.  ipecac, 

Calomelanos,  aa  gr.  x 


APPENDIX. 


615 


Sacchar.  albi,  gr.  xx.  1 

S.  One  or  two  grains  every  second  or 
third  hour,  as  an  expectorant  in  bronchial 
irritation.  Evanson  and  Maunsdl. 

'^  Decoct,  polyg.  seneg.,  giijss. 
Oxymel.  scillse,  5ij, 
Vini  ipecac,  3ij. 
Antim.  tart.,  gr.  j. 
S.  Ten  minims  to  a  scruple,  as  an  ex- 
pectorant. Evanson  and  Maunsdl. 

I^  Mist,  acacias,  iiss. 
Aquae  purse,  §iijss. 
Syrupi,  gss.    M. 
S.  A  teaspoonful  every  two  or  three 
hours,    for    an    infant   from    four  to  six 
months  old. 

g;  Rad.  seneg.,  3ss. 

Infus.  in  s.  q.  aq.  fervid. 

per  i  hor.  colatur,  §iv. 
Adde, 

AmmoniEBhydrochl.,  3ss. 
Syrup,  althseae,  ij. 
A  teaspoonful  every  two  hours  to  an  in- 
fant. Wendt. 

I^  Polygalae  senegse. 
Scillae,  aa  §j. 
Aquse,  ft)j. 
Mellis  despum.,  ftss. 
F.  Syrupus,  qucequse  unciae  cujus  adda- 
tur. 

Antimonii  tart,  granum. 

Coxe's  hive  syrup. 

I]e  Potass  tart.,  3j. 
Vin.  antim.,  3ss. 
Aquae  anethi,  §j. 
Oxymel.  scillae,  §ss. 
Ext.  glycyrrh.,  3j.    M. 
One  or  two  teaspoonsful  for  an  infant 
of  twelve  or  eighteen  months,  in  catarrhal 
fever.  Frankel. 

'^  Pulv.  ipecac,  gr.  iij. 
Pulv.  acaciae. 
Magnes.  carb.,  aa  3ss. 


Sacchari  adbi,  5j. 
M.     Ft.pulvisdivid.inxij    sequalcs  part. 
A  powder  every  two  hours  in  hooping- 
cough.  Volger. 

I^  Pulv.  acaciae,  3ss. 
Sacchari  purif ,  3j. 
Amyli,  gr.  x. 
M.  One  to  be  taken  frequently. 

Kirby. 

I^  Tinct.  opii,  gt.  j. 
Vin  ipecac,  gt.  iv. 
Carb.  sod.,  gr.  ij. 

To  be  given  in  a  little  sweetened  water. 
For  a  child  between  one  and  two  years. 
Pearson. 

I^  Tinct.  opii  camph.,  ^j. 
Vin.  antim.,  fss. 
Sue.  glycyr.,  3iij. 
Pulv.  g.  acaciae,  3ij. 
Aq.  fervent.,  §vj. 

A  teaspoonful  every  two  or  three  hours 
during  the  night,  to  a  child  six  months  old, 
in  troublesome  cough.  Dewees. 

'^  Emulsio.  amygd.,  ^iv. 
Syrup,  simpl,  §j. 
Gum.  tragacanth.,  gr.  vi, 

M.  To  be  given  by  the  teaspoonful. 
H.  des  Enf. 

I^  Hordei,  3vj. 
Gum.  acaciae,  3j. 
Aquae,  ftij. 
Boil  and  strain  them.     Add 

Sacchar.  alb.  q.  s. 
This  is  the  gummed  barley  water  men- 
tioned in  this  work. 

ASTRINGENTS. 

'^  Hydr.  c  creta,  3j. 

Pulv.  ipecac,  comp.,  Sij. 
Magn.  carb.,  3ss. 
Tere  bene  simul. 
Four  to  six  grains,  as  a  sedative  for  in- 
fants. Copland. 


616 


APPENDIX. 


^  Pulv.  acacise,  5j. 
Solve  in. 

Aq.  foeniculi,  5j-     Adde, 
Cretse,  3ss. 
Syrup,  althaeae,  oj- 
A  teaspoonful  every  tw^o  hours,  in  infan- 
tile diarrhoea.  Frdnkel. 

I^  Cretae  ppt.,  fss. 
Saponis  amygd. 
Pulv.  rheij  aa  3j, 
Hydr.  c.  creta,  3j. 
Ol.  fceniculi,  m  viij. 
Sacchar.  albi,  3ij. 
Tere  bene  simul. 
From  six  grains  to  half  a  drachm  twice 
or  thrice  a  day,  in  infantile  diarrhoea. 

Copland. 

I^  Hyd.  c.  creta,  3ss. 
Pulv.  cretsB  co.,  3j. 
Pulv.  tragacanth.  co.,  3ss. 
Divid  in  partes  x  aequales.     Sumat.  4? 
quaque  hora. 

In  diarrhcea,  for  an  infant  of  four  or  six 
months. 

5i  Cretae  ppt,,  5iij. 

Tinct.  thebaic,  gt.  xx.  vel  xxx. 
01.  cinnam.,  gt.  j. 
Sacchar.  alb.,  3ij. 
Aq.  font.,  iij. 

M.  A  teaspoonful  every  two,  three,  or 
four  hours.  Dewees. 

EXTERNAL  APPLICATIONS. 

I^  Antim.  tart.,  3j. 
Aq.  ferv.,  §j. 
Tinct.  cantharid.,  5j. 
An  embrocation,  in  hoopingcough. 

Struve. 

^  01.  oliv.,  fij. 
01.  succin. 
01.  caryoph.,  aa  §ss. 
An  embrocation,  in  hoopingcough. 

5;  Liniment  saponis,  iss. 
01.  succin.,  iss. 


In  hoopingcough.  These  embrocations 
should  be  applied  both  to  the  chest  and 
along  the  course  of  the  spine. 

I^  Sulph.  cupri,  3ij. 
Pulv.  cinchon.,   iss. 
Aquae,  §iv. 
To  be  applied  twice  a  day  to  gangrene 
of  the  cheek.  Dr.  Coates. 

15^  Sulph.  subUm.,  giv. 
Cerat.  eimpl.,  ftj. 
Used  in  tinea.  H.  des  Enfans. 

BATHS. 

Potassae  sulphur.,  iij. 
Aquoe,  tbj. 
This  bath  differs  from  the  artificial  Ba- 
rege water,  in  containing  half  the  quantity 
of  sulphuret  of  potass. 

Used  in  psora.  H.  des  Enfans. 

Sulph.  sublim. 
Acetatis  plunbi,  a  a  5j, 
Zinci  sulph.,  3ss. 

Used  in  psora. 

H.  de  la  Maternite. 


Syrup  papav.,  3ij, 
Decoc.  amyU,  iviij 
In  diarrhoea  of  infants. 

H.  de  la  MatemitS. 

I^  Cap.  papav..  No.  j. 
Decoc.  lini,  ftjjj 

H.  de  la  Maternite. 


1^  Cap.  papav.,  3iij. 
AqusB,  Ibj. 


B,  Amyli,  ij. 
Aquae,  Ibij. 


H.  des  Edfans. 


H.  des  Enfant. 


Y^  Flor.  anthemidis,  5ij. 
Aquae,  Ibj. 
Ft.  enema.    For  infantile  colic. 


APPENDIX. 


617 


PURGATIVES. 

5^  Pulv.  rad.  jalap.,  gr.  xxiv. 
Calomelanos,  gr.  iv. 
Sacchar.  alb.,  5ij. 

M.  Ft.  pulvis  divid  in  xij  partes  cequa- 
les. 

A  powder  twice  a  day  for  a  six 
months  infant,  in  obstruction  of  the  bow- 
els. Wendt. 

R  Calomelanos,  gr.  iij. 
Pulv.  rhei, 

Oleo-sacch.  foenic,  aa  3j. 
Ft.   pulvis.     One  third    of  the    above 
quantity  is  a  dose  for  an  infant,  as  a  laxa- 
tive. Fischer. 

I^  01.  ricini,  3iij — iv.- 
Pulv.  acaciae,  q.  s. 
Aq.  foenic  ,  5ij. 
Mannae,  §ss. 
Fiat  emulsio. 
A  dessert  spoonful,  repeated  every  hour 
until  it  operates.  Berends. 

I^  01.  ricini,  fss. 
Syrup,  rosse,  iss, 
Vitel.  ovi,  un. 
Tinct,  sennas,  3iss. 
One  or  two  teaspoonsful  for  an  infant, 

I^  Mannse,  §ss. 

Emulsio.  Arab.,  ^ss. 
Syrup,  violse,  3ij. 
Bene  admisce,  et  adde, 
Aquae  menth.,  §j.     M. 
S.  From  3j  to  3ij  every  third  hour,  until 
an  effect  is  produced. 

Evanson  and  Maunsell. 

15;  Infusi  sennse,  ij. 
Aquae  menthae,  5ss. 
Mannae,  3ij. 
Magnesiae,  3j. 
Tinct.  rhei,  5j. 
Syrup,  rosae,  3ij,     M. 
S.  From  5j  to  3ij  every  third  hour. 

Evanson  and  Maunsell. 


IJi  Sulph.  sub.,  gr.  x — xx. 
Mist,  acaciae,  3ij. 
Sacchar.  alb.  gss. 
Aq.  rosae,  3j. 
A  teaspoonful  hourly,  shaking  the  vial 
well  each  time ;  for  an  infant  in  the  first 
year.  Kcypp. 

5i  Fol.  sennae,  §ss. 
Aquae  ferv.,  Ibj. 
Sodae  sulph.,  ^ss. 
To  be  used  as  an  enema. 

H.  des  Enfans. 

B;  Magn.  calcin.,  3ss. 
Pulv.  rhei,  gr.  vj. 
Sacchar.  albi,  3j. 
01.  menth.,  gt.  vj. 
Aquae,  §iss. 
A  dessert  spoonful  every  two  hours. 
H.  d'Amer. 

I^  Mannse,  iiij. 
01.  amygd., 
Syrup,  gum.,  aa  ij. 
From  one  to  four  drachms  to  be  given  to 
young  infants,  as  a  mild  laxative. 

H.  cPAllem. 

I^  Decocti  hordei,  iv. 
Muriatis  sodae,  3iij. 
01.  olivarum,  3v,     M. 
To  be  used  as  an  enema. 


R  Vini  antim.,  gss. 
Syrup,  althaeas,  §j. 
A  teaspoonful  every  quarter  of  an  hour, 
to  a  child  three  or  four  months  old. 

Wendt. 

g;  Pulv.  ipecac.,  gr.  xij. 
Syrup,  simpl.,  |j. 

A  teaspoonful  every  quarter  of  an  hour, 
to  an  infant  five  or  six  months  old. 


"^  Vin.  antim.,  §ss. 
Oxymel  scillse,  3ij. 


78 


618 


APPENDIX. 


A  teaspoonful  for  an  infant  at  the  breast. 
Friinkel. 

5;  AqusB,  gj. 

Vini  ipecac,  gss. 
Syrupi,  gss. 

One  or  two  drachms  frequently,  till  vom- 
iting ensue. 

Evanson  and  Maunsell. 

I^  Pulv.  chel.  cancror.,  3ss. 
Antim.  tart.,  gr.  ij. 
M.  In  hoopingcough,  one  half  to  two 
grains^  according  to  the  age  of  the  child. 
Fothergill. 

TONICS  AND  STIMULANTS, 

^.  Ferri  tart.,  3j. 
Syrup,  simpl.,  q.  s. 
M.  Ft.  bol,  No.  iij. 
As  a  tonic  for  debilitated  infants. 

H.  des  Enfans. 

B;  Cinchonas,  §ss. 
Aquae,  Ibj.     M. 
To  be  used  as  an  enema  when  the  stom- 
ach rejects  cinchona. 

H.  des  Enfans. 

I^  Aquae  destillat.,  fiss. 
Quinge  dissulph.,  gr.  ij. 
Acid,  sulph.  arom.,  gtts.  xvj. 
Syrupi  caryoph.,  gss.     M. 
From  one  to  two  drachms  thrice  a  day. 
Evanson  and  Maunsell. 

1^  Sal.  martis,  gr.  ij. 
Acid,  sulph.,  gt.  X. 
Sacch.  alb.,  3j. 
Aquae  font.    M. 
Dose,  3j,  in  chronic  stage  of  cholera  in- 
fantum. Chapman. 

WINE  WHEY. 

I^  Lactis  vacc,  Oss. 
Vin.  alb.,  gj  vel  gij. 
Boil  the  milk,  then  add  the  wine. 


EXTERNAL    APPLICATIONS. 

^  Unguent,    cetacei,  ij. 
Oxidi  zinci, 

Pulv.  lycopodii,  aa  3ss. 
Useful  in  ulceration  of  the  eyelids. 

Huf eland. 

5k  Croci  sativ.,  5j. 
Aquae  fervent.,  §iv. 
Vin.  opii,  3j. 
Anodyne  collyrium.     To  be  used  when 
there  is  great  pain.  Jadelot. 

I^  Infus.  sambuci,  Ibj. 
Zinci  sulph ,  3j. 
Astringent  collyrium.     Much  used  in 
scrofulous  ophthalmia,  which  is  usually  ac- 
companied with  puriform  exudation. 

D'Huc. 

I^  Hydr.  deuto-chlorid.,  gr.  iv. 
Aq,  purae,  gviij. 

Used  in  syphilitic  ophthalmia. 

D'Huc. 

I]^  Rad.  althaeae,  3ij. 
Aqucc,  Ibj. 

Emollient  collyrium.     Used  in  inflamed 


conjunctivae. 


D'Huc. 


"^  Cerat.  simpl, ,  gij. 
Antim.  tart.,  3ij. 
Camphorae,  3j. 

To  be  used  by  friction,  to  excite  the 
skin ;  it  is  a  powerful  irritant  in  hooping- 
cough.  D^Huc. 

I^  Flores  anthemidis, 
Acet.  commun.,  a  a  fiv. 

A  common  revulsive. 

H.  des  Enfans. 

I^  Cataplasm  emolL,  Ibij. 
Ung.  resinos,  ij. 

M.  Useful  to  hasten  the  suppuration  of 
a  phlegmonous  tumor. 


APPENDIX. 


619 


g;  Pulv.  lini,  q.  s. 

Decoc.  rad.  alth.,  q.  s. 

M.  An  emollient  cataplasm. 

BATH   OF   BARGES   WATER. 

Potassoe  sulphur,  3ij. 
AquaB,  Ibc. 

For  psora  and  other  cutaneous  affec- 
tions. H.  des  Enfans. 

I^  Cataplasm,  emol.,  ^iv. 
Farinas  sinap.,  3iv. 
M.  Used  as  a  revulsive. 

H.  des  Enfans. 

STIMULANT. 

I^  Sp.  amnion,  arom.,  5ss. 
Syrup,  althaeas, 
Aquae  foniculi,  3j.     M. 

A  teaspoonful  for  an  infant  every  hour. 
Frdnkel. 

ALTERATIVE. 

Ijt  Calomelanos,  gr.  iij. 
Amyli,  3ss. 
Sacch.  albi,  3iss. 

M.  Ft.  pulvis  divid.  in  xii  partes  aequa- 
les. 

One  thrice  a  day  in  infantile  syphilis. 
Wendt. 

DIETETICS. 


Cinnamon,  1  drachm. 

Water,  1  pint. 

Boil  them  until  well  mixed,  then  add 
grated  nutmeg  and  sugar. 

Another  receipt. 

Boil  a  few  slices  of  the  crumb  of  bread 
with  a  blade  of  mace  in  a  quart  of  water 
about  two  minutes ;  then  taking  the  bread 
and  bruising  it  finely,  mix  it  with  as  much 
water  as  will  make  it  of  a  proper  consist- 
ence, and  sweeten  it.  If  wine  be  required, 
which  is  seldom  the  case,  it  ought  not  to  be 
boiled  with  the  water,  but  should  be  added 
afterwards. 

TAPIOCA   JELLY. 

Tapioca,        2  spoonsful. 
Water,  1  pint. 

Boil  it  until  it  assumes  an  appearance  of 
jelly,  then  add  sugar,  lemon  juice,  or  wine, 
if  necessary. 

PREPARED   ARROWROOT. 

Arrowroot,        1  tablespoonful. 
Sweet  milk,        ^  pint. 
Boil  them  over  the  fire  a  few  minutes, 
then  sweeten  them  with  loaf  sugar. 


Lean  beef  in  shreds,         1  lb. 
Water,  1  quart. 

Boil  for  twenty  minutes,  taking  off  the 
scum  as  it  rises ;  when  cold,  strain. 


RICE   WATER. 

Rice,  2  ounces. 

Water,  2  quarts. 

Boil  for  an  hour  and  a  half,  then  add  as 
much  sugar  and  nutmeg  as  may  be  re- 
quired. 


Wheat  bread. 


1  ounce. 


CHICKEN   WATER. 


Take  half  a  chicken,  divested  of  all  fat, 
and  break  its  bones ;  add.  to  this  half  a  gal- 
lon of  water,  and  boil  fifteen  minutes ; 
then  season  with  salt. 


STARCH   WATER. 


Starch, 
Cinnamon, 


1  ounce. 
1  drachm. 


620 


APPENDIX. 


Boiling  water,    3  pints. 
Boil  until  reduced  one  third,  and  strain. 

TOAST   WATER. 

Take  the  crumb  of  bread  toasted,  any 
quantity,  and  add  one  quart  of  boiling 
water. 

WHITE   DECOCTION   OF   SYDENHAM. 

Crumb  of  bread,  6  drachms. 
Calcined  hartshorn  shavings,  2  drach. 
Sugar,  1  ounce. 


Water,  1  quart. 
Boil  for  a  quarter  of  an  hour,  and  add 
infusion  of  canella,  2  drachms. 

COMPOUND    DECOCTION    OF    HARTSHORN, 
OR  WHITE   DECOCTION. 

Hartshorn  shavings,  1*  ounce- 
Crumb  of  bread,  1  ounce. 
Water,  1  quart  and  1  pint. 

Boil  until  reduced  to  a  third,  and  add  2 
ounces  syrup  of  quinces. 

H.  de  la  Ch. 


DOSES    OF    MEDICINE. 

Hufeland  has  drawn  up  the  following  scale  of  the  doses  of  medi- 
cine for  different  ages : 

Years 25  20  15  14  13  12  11  10     9     8     7    6    5    4    3    2     1 

Doses 40  35  30  29  28  27  26  25  24  23  22  21  20  18  16  13  10 

Months...ll  10    987654321^ 
9  8  7  6  5    4    2     1 

Suppose  the  dose  at  the  end  of  the  first  year  to  be  1,  then  at  the 
fifth  it  will  be  2  ;  at  the  fifteenth  3  ;  and  at  the  twenty-fifth  4.  In 
the  above  table  the  dose  for  an  adult  is  supposed  to  be  40  grains. 


THE    END. 


14  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BORROWED 

BIOLOGY  LIBRARY 

TEL.  NO.  642-2532 

This  book  is  due  on  the  last  date  stamped  below,  or 

on  the  date  to  which  renewed. 

Renewed  books  are  subject  to  immediate  recall. 

Ml"  .12  1f)7, 

/ 

WAR  25  1971      a 

*. 

APR  -  8  1971 

.. 

JUN  1  S  1971 0  ", 

JUN  3  0  1971 

.\ 

SEP!in  mi    2 

MAE  -\oW\q 

APR  1  71972 

nriA  J-  •  1  Ji t- 

JUN  15  197Z  #5 

I: 

h 

Berkeley 

